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85–440 2013

REFORMING SGR: PRIORITIZING QUALITY IN A 

MODERNIZED PHYSICIAN PAYMENT SYSTEM 

HEARING 

BEFORE THE

SUBCOMMITTEE ON HEALTH 

OF THE

COMMITTEE ON ENERGY AND 

COMMERCE 

HOUSE OF REPRESENTATIVES 

ONE HUNDRED THIRTEENTH CONGRESS 

FIRST SESSION 

JUNE 5, 2013 

Serial No. 113–50 

( 

Printed for the use of the Committee on Energy and Commerce 

energycommerce.house.gov 

(II) 

COMMITTEE ON ENERGY AND COMMERCE 

FRED UPTON, Michigan 

Chairman 

RALPH M. HALL, Texas 

JOE BARTON, Texas 

Chairman Emeritus 

ED WHITFIELD, Kentucky 

JOHN SHIMKUS, Illinois 

JOSEPH R. PITTS, Pennsylvania 

GREG WALDEN, Oregon 

LEE TERRY, Nebraska 

MIKE ROGERS, Michigan 

TIM MURPHY, Pennsylvania 

MICHAEL C. BURGESS, Texas 

MARSHA BLACKBURN, Tennessee 

Vice Chairman 

PHIL GINGREY, Georgia 

STEVE SCALISE, Louisiana 

ROBERT E. LATTA, Ohio 

CATHY MCMORRIS RODGERS, Washington 

GREGG HARPER, Mississippi 

LEONARD LANCE, New Jersey 

BILL CASSIDY, Louisiana 

BRETT GUTHRIE, Kentucky 

PETE OLSON, Texas 

DAVID B. MCKINLEY, West Virginia 

CORY GARDNER, Colorado 

MIKE POMPEO, Kansas 

ADAM KINZINGER, Illinois 

H. MORGAN GRIFFITH, Virginia 

GUS M. BILIRAKIS, Florida 

BILL JOHNSON, Missouri 

BILLY LONG, Missouri 

RENEE L. ELLMERS, North Carolina 

HENRY A. WAXMAN, California 

Ranking Member 

JOHN D. DINGELL, Michigan 

Chairman Emeritus 

EDWARD J. MARKEY, Massachusetts 

FRANK PALLONE, JR., New Jersey 

BOBBY L. RUSH, Illinois 

ANNA G. ESHOO, California 

ELIOT L. ENGEL, New York 

GENE GREEN, Texas 

DIANA DEGETTE, Colorado 

LOIS CAPPS, California 

MICHAEL F. DOYLE, Pennsylvania 

JANICE D. SCHAKOWSKY, Illinois 

JIM MATHESON, Utah 

G.K. BUTTERFIELD, North Carolina 

JOHN BARROW, Georgia 

DORIS O. MATSUI, California 

DONNA M. CHRISTENSEN, Virgin Islands 

KATHY CASTOR, Florida 

JOHN P. SARBANES, Maryland 

JERRY MCNERNEY, California 

BRUCE L. BRALEY, Iowa 

PETER WELCH, Vermont 

BEN RAY LUJAN, New Mexico 

PAUL TONKO, New York 

(III) 

SUBCOMMITTEE ON HEALTH

JOSEPH R. PITTS, Pennsylvania 

Chairman 

MICHAEL C. BURGESS, Texas 

Vice Chairman 

ED WHITFIELD, Kentucky 

JOHN SHIMKUS, Illinois 

MIKE ROGERS, Michigan 

TIM MURPHY, Pennsylvania 

MARSHA BLACKBURN, Tennessee 

PHIL GINGREY, Georgia 

CATHY MCMORRIS RODGERS, Washington 

LEONARD LANCE, New Jersey 

BILL CASSIDY, Louisiana 

BRETT GUTHRIE, Kentucky 

H. MORGAN GRIFFITH, Virginia 

GUS M. BILIRAKIS, Florida 

RENEE L. ELLMERS, North Carolina 

JOE BARTON, Texas 

FRED UPTON, Michigan (ex officio) 

FRANK PALLONE, JR., New Jersey 

Ranking Member 

JOHN D. DINGELL, Michigan 

ELIOT L. ENGEL, New York 

LOIS CAPPS, California 

JANICE D. SCHAKOWSKY, Illinois 

JIM MATHESON, Utah 

GENE GREEN, Texas 

G.K. BUTTERFIELD, North Carolina 

JOHN BARROW, Georgia 

DONNA M. CHRISTENSEN, Virgin Islands 

KATHY CASTOR, Florida 

JOHN P. SARBANES, Maryland 

HENRY A. WAXMAN, California (ex officio) 

(V) 

C O N T E N T S 

Page 

Hon. Joseph R. Pitts, a Representative in Congress from the Commonwealth 

of Pennsylvania, opening statement ................................................................... 1 

Prepared statement .......................................................................................... 28 

Hon. Donna M. Christensen, A Representative in Congress from the Virgin 

Islands, opening statement ................................................................................. 29 

Hon. Fred Upton, a Representative in Congress from the State of Michigan, 

opening statement ................................................................................................ 30 

Prepared statement .......................................................................................... 31 

Hon. Ralph M. Hall, a Representative in Congress from the State of Texas, 

prepared statement .............................................................................................. 129 

Hon. Henry A. Waxman, a Representative in Congress from the State of 

California, prepared statement ........................................................................... 129 

Hon. Frank Pallone, Jr., a Representative in Congress from the State of 

New Jersey, prepared statement ........................................................................ 130 

WITNESSES

Cheryl L. Damberg, Ph.D., Senior Policy Researcher, Professor, Pardee Rand 

Graduate School ................................................................................................... 33 

Prepared statement .......................................................................................... 36 

Answers to submitted questions ...................................................................... 140 

William Kramer, Executive Director for National Health Policy, Pacific Business Group on Health .......................................................................................... 54 

Prepared statement .......................................................................................... 56 

Answers to submitted questions ...................................................................... 156 

Jeffrey B. Rich, M.D., Immediate Past President of the Society of Thoracic 

Surgeons, Director at Large, Virginia Cardiac Surgery Quality Initiative ..... 69 

Prepared statement .......................................................................................... 71 

Answers to submitted questions ...................................................................... 162 

Thomas J. Foels, M.D., M.M.M., Executive Vice President, Chief Medical 

Officer, Independent Health ................................................................................ 82 

Prepared statement .......................................................................................... 85 

Answers to submitted questions ...................................................................... 232 

SUBMITTED MATERIAL

Discussion draft ....................................................................................................... 3 

Statement of National Senior Citizens Law Center, submitted by Mrs. 

Christensen ........................................................................................................... 131 

Statement of Alliance of Specialty Medicine, submitted by Mrs. Christensen ... 137 

(1) 

REFORMING SGR: PRIORITIZING QUALITY IN 

A MODERNIZED PHYSICIAN PAYMENT SYSTEM 

WEDNESDAY, JUNE 5, 2013 

HOUSE OF REPRESENTATIVES, 

SUBCOMMITTEE ON HEALTH, 

COMMITTEE ON ENERGY AND COMMERCE, 

Washington, DC. 

The subcommittee met, pursuant to call, at 10:00 a.m., in room 

2123, Rayburn House Office Building, Hon. Joseph R. Pitts (chairman of the subcommittee) presiding. 

Present: Representatives Pitts, Burgess, Shimkus, Rogers, Murphy, Blackburn, Gingrey, Lance, Cassidy, Guthrie, Griffith, Bilirakis, Ellmers, Barton, Upton (ex officio), Dingell, Capps, 

Schakowsky, Green, Barrow, Christensen, Castor, Sarbanes, and 

Waxman (ex officio). 

Staff Present: Clay Alspach, Chief Counsel, Health; Gary Andres, 

Staff Director; Mike Bloomquist, General Counsel; Sean Bonyun, 

Communications Director; Matt Bravo, Professional Staff Member; 

Steve Ferrara, Health Fellow; Julie Goon, Health Policy Advisor; 

Sydne Harwick, Legislative Clerk; Sean Hayes, Counsel, O&I; Robert Horne, Professional Staff Member, Health; Katie Novaria, Professional Staff Member, Health; Andrew Powaleny, Deputy Press 

Secretary; Krista Rosenthall, Counsel to Chairman Emeritus; Chris 

Sarley, Policy Coordinator, Environment & Economy; Heidi Stirrup, Health Policy Coordinator; Lyn Walker, Coordinator, Admin/ 

Human Resources; Alli Corr, Minority Policy Analyst; Amy Hall, 

Minority Senior Professional Staff Member; Elizabeth Letter, Minority Assistant Press Secretary; and Karen Lightfoot, Minority 

Communications Director and Senior Policy Advisor. 

OPENING STATEMENT OF HON. JOSEPH R. PITTS, A REPRESENTATIVE IN CONGRESS FROM THE COMMONWEALTH 

OF PENNSYLVANIA 

Mr. PITTS. The subcommittee will come to order. The chair will 

recognize himself for an opening statement. 

On February 7th and April 3rd, 2013, the Energy and Commerce 

and Ways and Means Committee Republicans released a threephased outline for permanently repealing the Sustainable Growth 

Rate, the SGR, and moving toward a Medicare reimbursement system that rewards quality over volume. Stakeholder feedback followed each release and has been integral to the development of this 

2 

policy, culminating in the draft legislative framework released on 

May 28th. 

[The discussion draft follows:] 

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[DISCUSSION DRAFT] 

• REFORM OF SUSTAINABLE GROWTH RATE (SGR) 

AND MEDICARE PAYMENT FOR PHYSICIANS' 

SERVICES. 

(a) STABILIZI~G }1-'EE UPD:\TES (PIL\SE 1).-

(1) REPEAL en<' SGR PAYJ\lE~T l\lETIIODOLOGY.-Section 1848 of the Social Seeurity Act 

(42 U.S.C. 1395w-4) is amended-

(A) in subsection (d)-

(i) in paragraph (l)(A), by inserting 

"or a subsequent paragraph or section 

1848A" after "paragraph (4)"; and 

(ii) in paragraph (4)-

(I) in the heading, by striking 

")'EARS BEGI)iNI~G WITH 2001" and 

inserting "2001, 2002, A~D 2003"; and 

(II) in subparagTaph (A), by 

striking "a year beginning with 2001" 

and inserting "2001, 2002, and 

2003"; and 

(B) in subsection (f)-

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1 (i) in paragraph (I)(B), by inserting 

2 "through 2013" aftE'l' "of such succeeding 

3 YE'ar"; and 

4 (ii) in paragraph (2), by insE'rting 

5 "and ending with 2013" after "bebrinning 

6 with 2000". 

7 (2) UPDATE OF M'rES FOR [PERIOD OF STA8 BILITy]'-Subsection (d) of section 1848 of the So9 cial Security Act (42 U.S.C. 1395w-4) is amended 

10 by adding at the end thE' following' ne,,, paragraph: 

11 "(15) UPDATE FOR [PERIOD OF STABILITY].-

12 The update to thE' single cOlwersion factor estab13 lished in paragraph (I)(C) for [the period of sta14 bility (as defined in __ )] shall be [ ___ ].". 

15 (b) UPDATE IXCEI\'TIYE PROGRAM (PIL\SE II).-

16 (1) II\' GEKEHAL.-Section ]848 of such Act 

17 (42 U.S.C. 1395w-4), as amended by subsection (a), 

18 is further amended in subsection (d), by adding at 

19 thE' E'nd the following new paragraph: 

20 "(16) Cm .. ;YERSIO:,\ FACTOI{ BEGIXXL\,G WITH 

21 [J<'IRST YEAR AFTER PERIOD OF STABILITy]'-The 

22 single conwrsion factor established in paragraph 

23 (I)(C) for each year beginning with [the first YE'ar 

24 after the period of stability] shall be [determined in 

25 accordance with section 1848A( e)] .". 

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1 (2) ESTABLIsmm.'JT OP PROGRA.rI.-Part B of 

2 title XVIII of the Social Security Act (42 U.S.C. 

3 1395w-4 et seq.) is amended by adding at the end 

4 the following new section: 

5 "SEC. 1848A. FEE SCHEDULE PROVIDER COMPETENCY UP6 DATE INCENTIVE PROGRAM. 

7 "(a) ESTABLIsn:VlE:-J'l'.-

8 "(1) I:\' GE:-JERAL.-The Secretary shall estab9 lish a fee schedule provider competency update in10 centive program (in this section referred to as the 

11 'update incentiw program') under which12 "(A) the Srcretary shall, in accordance 

13 with subsection (b), approve and publish a final 

14 quality measure set for each peer cohort identi15 fied under paragTaph (1) of such subsection; 

16 "(B) each fee schedule provider17 "(i) self-identifies, in accordance with 

18 subsection (b)(l), within such a peer co19 hort; and 

20 "(ii) provides information on each 

21 quality measure 'within such a final quality 

22 measure set applicable to such peer cohort 

23 with respect to which such provider shall 

24 be aRseRRed for purposes of determining for 

25 [years beginning with the firRt year after 

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the period of stability] the [quality-based 

update adjustment under subsection (e)] 

applicable to such provider; 

"(C) the Secretary shall develop and apply, 

111 aecordance with subsection (d), appro6 priate7 ["(i) methodologies for assessing the 

8 performance of fee schedule providers ,\ith 

9 respect to such measures ineluded "ithin 

10 the measure sets applicable to the peer coII horts of such providers; and] 

12 "(ii) methods for eolleeting informa13 tion needed for such assessments (which 

14 shall involye the minimum amount of ad15 ministrative burden needed to ensure reli16 able results); and 

17 "(D) based on such assessments, the Sec18 retary shall determine the applieable [quality19 based update adjustments under subsection 

20 (e)]. 

21 "(2) FEE SCHEDUT,g PROVJDER DEFI':\ED.-In 

22 this section, the term 'fee schedule provider' means 

23 a [physician, practitioner, or other] supplier that 

24 furnishes items and services that are paid under the 

25 fee schedule established under section 1848. 

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1 "(;3) CO:\'St:LTATIO~ WITH ;\lEDICAI, SPECL~TY 

2 ORG:L,\IZATIOXS A~D OTHER RELEYAi'\T STAKB3 IIOLDERS.-The SecretaI)' shall consult ,,1.th medical 

4 specialt;v organizations and other relevant stakeS holders, including State medical societies, in car6 ryi.ng out this section. 

7 "(4) l\10DIFICATIO~ FOR XO?\T-PIIYSICIA."\T FEE 

8 SCHEDCLE PROVIDERS WHO ARE AITHORIZED TO 

9 BILL l\1EDIC.illE DIRECTLY POR REBlBURSEME?\TT.-

10 Not later than [--] , the Secretary shall deter11 mine how to apply the update incentive program to 

12 fee schedule prmi.ders who are not physicians de13 scribed in section 1861(r)(I). [Duplicative with 

14 paragraph (3)'1: In making such determination, the 

15 Secretary shall consult ,,1.th relevant stakeholders.] 

16 In appl;\1.ng this paragraph, the Secretm)T shall at a 

17 minilllum determine if there are applicable quality 

18 measures [selected] under subseetion (b) that can 

19 be utilized for determinillg applicable update adjust20 ments to the fee schedule under [subseetioll (e)] for 

21 such fee schedule prm1.ders. If adequate measures 

22 are not m'ailable, the Secretary shall apply a similar 

23 [performance]/[competency]-based program to de24 tel'mine the [quality-based update adjustment under 

25 subsection (e)] for such fee schedule providers. 

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1 ["(5) ELECTIO:-.J POR APPLICATI00: AT GROt-P 

2 PRACTICE OR I:-.JDlYIDUAL PHYSICL'L'{ LEYEL.-[Pol3 icy question ~r luish to spec~f'ically provide for an elec4 tion opportunity, or remain silent (in which case the 

5 Secretary may decide to apply asscssments at a group 

6 level, but the element spec~fically allowing the ])1'0-

7 1,iders and groups to make an election would not be 

8 implied):] For purposes of this section, in the ease 

9 of a fee schedule prmider who participates in a 

10 [group practice] [Defi:niMon? As defined by the Sec11 retary, following the sect1:on 1848(0) or 1848(m) 

12 model? As such term is definedw section 

13 1877(h)(4)?], a fee schedule prmider may elect, III 

14 a form and manner specified by the Secretary, to 

15 apply at either the group practice leyel or individual 

16 provider level the [applicable final quality measure 

17 set] approyed under subsection (b), performance on 

18 quality, composite scores, and the update adjust19 ments under this section. Such election made by a 

20 fee schedule prOvider shall appl~' "ith respect to all 

21 measures within such set, performance scores, and 

22 update adjustments for such prmider. The feedback 

23 and performance data required to be provided by the 

24 Secretary under subsections (b)(5) and (g') shall be 

25 provided to a fee schedule prOvider regardless of the 

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1 election made by the proyider under this paragTaph. 

2 [Review: How would tMs apply in tlw case of a pl'O3 vwel' parf1:cipating ,in multiple pmchces? Would the 

4 election be on an indiv'idual provider level or would 

5 all pr01'iders within a group have to collectively make 

6 this election? U' t1w assessment 1:S based on the gr'01lP 

7 level, how is feedback to be provided for the indi8 vidu.al?]] 

9 "(b) Ql:AUTY l\'IEASl;RES FOR CmIPETE::\,CY As10 SESS?l1E::\'TS.-

11 "(1) ESTABIJISID1E:,{T OF LIST OF PEER CO12 HORTS.-[Not later than __ ,] the Secretary shall 

13 identif;v ([and publish?] a list [I~ this list to be up14 dated?]) of peer cohorts (each in this section re15 ferred t.o as a 'peer cohort') \\;th respect to which 

16 fee schedule pro,;ders will self-identif;v [through a 

17 process and at such time as specified by the Sec18 retary Review: How is the self' identUication to be 

19 'approved by the Secretary'?] for purposes of this 

20 section and with respect to a performance period de21 scribed in subsection (d)(3) for a year beginning 

22 with [the first year after the period of stability]. 

23 Such list shall include as a peer cohort the [each 

24 provider specialty [in which the American Board of 

25 Medical Specialties offers certification]/[defined by 

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1 the American Board of lVIedical Specialties as of 

2 ___ ll and any other cohort established by the Sec3 retary to capture elassifications of proyiders across 

4 such proyider specialties. 

5 "(2) ESTABLISmIE);,T OF CORE COllIPETE);,CY 

6 CA'I'EGOIUES ,WD IDE.NTIFICATIO-" OF AREAS 01<' 

7 );,EED l<'OR QUALITY :lIEASURES.-The SecretaIT 

8 shall conwne multi-stakeholder gTOUpS to9 "(A) establish core competency categories 

10 [for all peer cohorts]' which shall identify 

11 areas that are to be assessed by the quality 

12 measures selected under this subsection for ill13 elusion in final quality measure sets by which 

14 fee schedule prmiders [in such cohorts] are to 

15 be assessed under subsection (d); and 

16 "(B) identify areas and peer cohorts for 

17 which there are insufficient quality measures to 

18 address the categorics established under sub19 paragTaph (A). 

20 "(3) QCALITY lIIEAS1.-RES DEv"'ELOP:lIE-"T.-The 

21 Secretary shall establish a process for the dewlop22 ment of quality measures under this paragraph for 

23 purposes of potential inclusion of such measures [in 

24 measure sets under paragTaph (4)]. Under such 

25 process, the Secretary shallf:WHLCI0528131052813.001.xml 

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"(A) provide for the coordination of devel2 oplllent of such measures across fee schedule 

3 providers and other relevant stakeholders; 

4 "(B) request from [medical specialty orga5 nizations and other relevant stakeholders]/ 

6 [consensus-based entities] [representing the 

7 peer cohorts] best practices and clinical prac8 tice guidelines for the development of quality 

9 measures ["ithin the core competency cat10 egories established under paragraph (2)'1] for 

11 potential inclusion of snch measures in final 

12 quality measnre sets under paragraph (4)(l<~); 

13 "(C) ensure the core competency categories 

14 and peer cohorts are addressed; and 

15 "(D) ensure that all quality measures de16 veloped under this paragraph are developed 

17 "ith consideration of best clinical practices. 

18 "(4) [QUAUTY -'iEASGRES SEl>ECTIO=,,]/[SE19 LEcno:\, A.'\D APPROvAl> OF QUALITY :lIK\.Sl:RE 

20 SETS].-

21 "(A) IK GE="ERAh-The Secretary shall, 

22 111 accordance "ith this paragraph, prmide for 

23 a quality measures process to approve final 

24 quality measnre sets for peer cohorts. Each 

25 such final measure set shall be composed of the 

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quality measures w'ith respect to ,vhich fee 

schedule prm'iders ,,'ithin such peer cohort shall 

be assessed under subsection (d). Under such 

process the Secretary shall establish, and prior 

to making the request under subparagraph (C) 

make publicly available, criteria for selecting 

such measures [for potential inelusion in such 

final qualit~T measure sets]. 

"(B) SOFRCES OF l\fEASURES.-A quality 

measure selected [for inclusion in a [prm'isional] core quality measure set] under the 

process under this paragraph may be-

"(i) an [existing] [TFhat if a measure 

,is endorsed in the fidure?] quality measure 

that has been endorsed by [a consensusbased entity]; 

"(ii) a quality measure developed 

under paragraph (3); or 

"(iii) a quality measure that is developed by a [medical speeialty organization 

or other relevant stakeholder] [and submitted under subparagraph (C)~]. 

"(C) SOLIC[TATIO~ OF PFBLIC Ql:ALITY 

~IEASFRE I~PFT.-Not later than [--] , the 

Secretary shall request [medical specialty orga-

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11 

nizations and other] relevant stakeholders to 

identitT and submit to the Secretary quality 

measures for selection nnder this paragraph. 

"(D) PROVISIO:-JAL CORE :lIEASGRE 

SE'l'S.-

"(i) I:-J GEXERAh-Under the process 

established under subparagraph (A), [not 

later than __ ,] the Secretary shall select 

quality measures described in subparagraph (B) [applicable to a peer cohor1] to 

be included in a provisional core measure 

set [for such cohort]. Any [applicable] 

qnality measure developed under the process established under paragraph (3) may 

be included in a prm'isional core measure 

set. 

"(ii) TRAXSPAREXCy.-L4.ny deadline 

for pu.blic availability?] The Secretary 

shall make publiely available, including by 

publishing in specialty-appropriate peer-reviewed journals, [each applicable] provisional core measure set under clause (i) 

and the method for dcveloping (and selecting] measures included within such set. 

[Specs: 'Create exception tlwt in event soci-

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ety deel1:nes, Secretary can still go fal'ward 

in pmcess.' What does that en~eption mean' 

Is this in the case a specialty society does 

not 1.iJant to pltblish the core seU] 

"(E) PUBLIC COl\J:\IEl\"'r.-Under the process established under subparagTaph (A), before 

a provisional core measure set under snbparagraph (D) ma:v be approved as a final quality 

llleasure set under subparagraph (F) the SecretaI)-- shall provide for a reasonable public 

comment period on the provisional core measure 

set. 

"(F) :B~Il\"AL ]\IEASt'RE sl'JTs.-At least 

[ __ ] days before the first day of a performance period described in subsection (d)(3) [and 

taking into account public comment received 

pursuant to subparagraph (E)l the Secretary 

shall approve and publish a final quality measure set for eaeh peer eohort. 

"(5) Fl'JEDBACK.-

"(A) I:,\I'fL\L FEEDBACK PERIOD.-Each 

fee schedule provider self-identified with respect 

to a peer ('ohort shall, before any assessment of 

the fee schedule provider under subsection (d) 

for determining the applicable update atljust-

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ment under subsection (e) for such provider 

and the year involved, have a [ __ ] period 

during which the provider shall report on the 

applicable quality measures and receive feedback on the performance of sueh provider with 

respect to such measures. 

"(B) FEEDBACK.-'rhe Secretary shall 

8 provide each fee schedule provider with feed9 back on the performance of such provider "ith 

1 0 respect to quality measures "ithin the final 

11 measure set approYed under paragraph (4) (F) 

12 for the applicable performance prriod and the 

13 peer cohort of surh provider. 

14 "(c) GE::\ERAL PROVISIOXS 1\]>PLICABLE TO .Anop15 TIO~ OI<' ALI, ME"-\.Sl;RES.-

16 "(1) R-\.XGE OF }IEASURES.-In can}ing out 

17 subsection (b), the Secretary shall, to the greatest 

18 extent practicable and for each peer cohort, [select] 

19 a sufficient number of qnality measures for potential 

20 inclusion of such measures [in measure sets under 

21 paragraph (4)]. 

22 "(2) Al,\XUAL REVIEW A~D UPDATES.-

23 "(A) I" GEXERAL.-The Seeretary shall 

24 reVlewf:WHLCI0528131052813.001.xml 

May 28. 2013 (8:38 a,m.) 

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85440.014

F:\PIH13ICMS\.\1EDCRIECRISGR-EClOXML 

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2 

3 

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9 

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19 

20 

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22 

23 

24 

25 

f:IVHLC\052B13\052B13.001.xml 

May 2B, 2013 (B:3B a.m.) 

14 

"(i) the quality measures selected 

under subsection (b)( 4) for inclusion in 

final qualit:v measure sets nnder subparagraph (F) of such subsection for each year 

such measures are to be applied under subsection (e) to ensure that such measures 

continue to m('('t the conditions applicable 

to such measures foT' such selection; and 

"(ii) the final quality measures sets 

appT'owd under subsection (b) (4)(}<"") for 

each year sueh set is to be applied to peer 

cohorts of fee schedule providers to ensure 

that each applicable set continues to meet 

thc conditions applicable to such sets for 

such approval. 

"(B) IXPUT FRO)r STAKEHOLDERS.-For 

purposes of' condueting' the review under subparagraph (A), the SecretaI~T shall request medieal speeialty organizations and other relevant 

stakeholders to, as needed, identify and submit 

to thc SecretlU~' updates to quality measnres 

selected under subsection (b)(4) as well as any 

additional quality measures. The Secretary shall 

[ __ ] review submissions under this subparagTaph. 

(55050114) 
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85440.015

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lJ)[S(TSS[O:-J DRAr''!'] 

2 

3 

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5 

6 

7 

8 

9 

10 

11 

12 

13 

14 

15 

16 

17 

18 

19 

20 

21 

15 

"(C) UPDATEs.-Based on the review eondueted under [this paragraph] for a ~-ear, the 

Seeretary- shall as needed-

"(i) select additional, and updates to, 

quality measures under subseetion (b) for 

potential inC'lusion in [final quality measure sets under paragraph (4)(F) of such 

subsection] in the same manner as the 

Secretary seleets such quality measures 

under such subsection; and 

"(ii) modify final quality measure sets 

approved under subsection (b)( 4)(F) [in 

the same manner as the Secretar~- approves such sets under such subsection]. 

In the case of a modification under clause (ii) 

that removes a quality measure from a final 

quality measure set, such modification shall not 

apply under this subsection unless notification 

of such modification is made available to all applicable fee schedule prm-iders. 

"(3) COORDIXATIOX WI'l'H EXISTIXG PRO22 GRA:\IS.-The Secretary' shall, as appropriate, coordi23 nate [the selection of] quality measures under sub24 section (b) with existing measures and requirements, 

25 such as the development of the Physician Compare 

f:IVHLCI0528131052813.001.xml 

May 28, 2013 (8:38 a.m.) 

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85440.016

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[DIS(TSSIOl\ DRAFT] 

16 

1 'Vebsite under section 1848(m)(5)(G). To the eJ\.-tent 

2 feasible, such measures should align with measures 

3 used under similar illeentiYe programs of other pay4 ers and with measures in use under other provisions 

5 of section 1848. The Secretary shall explore options 

6 for combining performance data from incentive pro7 grams with similar eOllllllercial payer data to develop 

8 a more comprehensive picture of fee schedule pro9 videI' performance that can be shared with con10 sumers and providers to improve performanee. 

11 ["(4) ADOPTlO:-'; OF ADDITIOl\AL l\IEASCRES.-

12 [Is this needed? If so, why?] The Secretary shall13 ] 

14 ["(A) determine whether or not to select 

15 additional or updates to quality measures under 

16 [paragraph (2)(C)(i)]; and] 

17 ["(B) make determinations as to the need 

18 to approve modifications under paragraph 

19 (2)(C)(ii).] 

20 "(d) ASSESSI:\G PERFOR\IAXCJ<J WITH RESPECT TO 

21 FI:\AL qU~\LITY MEAS{TRI~ SETS FOR lU'PLICABLE PEER 

22 COHORTS.-

23 "(1) ESTABLISHl\IEl\T OF METHODS FOR AS24 SESSl\IE:\T.-

f:WHLC\052B13\052B13.001.xml (55050114) 

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f:WHLC\052813\052813.001.xml 

May 28. 2013 (8:38 a.m.) 

17 

"(A) Ix GEXERAL.-The Seeretary shall 

establish one or more methods, applicable to 

eaeh year bef:,rinning with [the first year after 

the period of stability], to assess the performance of a fee sehedule IWoyider with respect to 

eaeh qualit~T measure included within the [final 

quality measure set appro\'ed under subsection 

(b)( 4)(F) applicable for the performance period 

established under paragraph (3) for such year 

to the peer eohort in whieh the prmider selfidentified under subsection (b)(l)] for such 

performanee period and compute a composit.e 

qualit~T score for such provider for such performance period. Such methods shall include 

methods for eollecting fee sehedule prmider information in order to make such assessments. 

"(B) l\TETHODS.-Such methods shall, 

"ith respect to a fee schedule prmider-

"(i) [Review:] provide that. the performanee of such provider shall be assessed 

for a performance period established under 

paragraph (3) with respect to the [quality 

measures "ithill the final quality measure 

set for such period for the peer eohort of' 

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[Dl8CFSSlOX DRAP'f] 

18 

such proyider and OIl which information is 

2 collected from such prm'ider]; and 

3 "(ii) allow for the collection and utili4 zation of data from registries or electronic 

5 health records. 

6 "(C) WEIGHTIXG OF' :\1EAsrREs.-Such a 

7 method may prm'ide for the assignment of dif8 ferellt scoring weights based on type or cat9 egor,v of qualit,v measure. 

10 "(D) II\TEGRATIOI\ (W PHYSICL\S QrAL11 ITY PROGRA:\IS.-In establishing such methods, 

12 the Secretary shall, as appropriate, incorporate 

13 comparable physician quality incentive pro14 grams, such as under subsections (k), (n), and 

15 (p) of section 1848. 

16 ["(2) USE OF SPECIALTY REGISTRIES.-For 

17 purposes of this subsection, the Secretary [may]/ 

18 [shall] use data from qualified clinical data reg19 istries that meet the requirements established under 

20 section 1848(m)(3)(E).] 

21 "(3) PEHFOHlVL\XCE PERIOD.-Not later than 

22 [ __ ], the Secretary shall establish a period, with 

23 respect to a year, to assess under this subsection 

24 performance of fee schedule prm'iders ,,'ith respect 

25 to quality measures. 

f:IVHLCI0528131052813.001.xml 

May 28,2013 (8:38 a.m.) 

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85440.019

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[DISCrSSIOK DRAFT1 

19 

"(e) UPDATE ADJl:STl\1EKT TAKIKG Il"TO ACCOPl"'f 

2 ASSESS;\1EK'TS \Vrl'II RESPECT TO QUALITY J\IEAS3 CRES.-[ __ 1 

4 "(f) TRAKSITIO:\T FOR NEW FEE SCIIEDCLE PROS \lDERS.-

6 "(1) I:\T GEl"ERAL.-In the case of a new fee 

7 schedule provider [there shall be __ 1. 

8 "(2) NEW FEE SCHEDCLE PROVIDER DE9 FIKED.-For purposes of this subseetion, the term 

10 'new fee schedule provider' means a physician, pmc11 titioner, or other supplier that first becomes a fee 

12 schedule provider (and had not previously submitted 

13 claims under this title as a perSOll, as an entity, or 

14 as part of a physician gTOUp or under a different 

15 billing number or' ta.\: identifier). 

16 "(g) FEEDBACK; EDCCATIO:\T; RECOKSTDER.:\TIOl".-

17 [Review Telationship with feedback provision u ndeT sub18 section (0)(5).] The Secretary shall give fee schedule pro19 ,riders feedback to assess their progress. 

20 "(h) OPT OCT FOR PROVIDERS PAID UK'DER ALTER21 :\TATIVE PAYlIIEKT J\IODELS.-

22 "(1) Ix GEK'ERAL.-Payment for senrices that 

23 are provided by a fee schedule prmrider under an ap24 proved ~AlternatiYe Payment Model shall be made in 

25 accordance "rith the payment arrangement under 

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May 28, 2013 (8:38 a.m.) 

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[DlS(TSSIO)'[ DRAPT] 

20 

1 such model [instead of in accordance ,~ith the up2 date incentiye program]. [Beginning "ith 

3 [20 __ ], the Secretary shall identifY [and publish 

4 in the Federal Register"?] such models applicable 

5 under this subsection for such year.] 

6 "(2) APPROYED ALTERXATIYE PADIE;\'T 

7 :.IIODEL; ALTER,,;\TIYE PADIE"T ~IODEL.-For pur8 poses of this subsection: 

9 "(A) ApPIWYED ALTER"ATIYE PAYlIIE:\'l' 

10 :.IIODEL.-The term 'approved Alternative Pay11 lllent Model' means an Alternative Payment 

12 Model that is developed by the Secretary under 

13 paragraph (3) or proposed by an entity and ap14 proved by the Secretary under paragraph (4). 

15 "(B) ALTER-"'ATIVE PA1~IEi\T ~IODEL.-

16 The term '.AlternatiYe Payment Model' or 

17 'AP.l\i' llleans a mechanism by which payment 

18 under this title is made to a [fee sehedule pro19 ,icier?] for most or all of the items and senices 

20 furnished by such provider. Such a mechanism 

21 shall have appropriate protections to assure 

22 that changes in care associated "ith the appli23 cation of the AP.l\I "ill not reduce the quality 

24 or access to care for indi,iduals enrolled under 

f:WHLCI0528131052813.001.xml 

May 28, 2013 (8:38 a.m.) 

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[DISCTSSIOK DRAPTl 

21 

1 this part. Such a mechanism may include, but 

2 not be limited to, any of the following: 

3 "(i) Accountable Care Organizations. 

4 "(ii) 'l\fedical Homes. 

5 "(iii) Bundled payments. 

6 "(3) DE\TELOPi\1E::\,'r BY SECRETARY OF ALTER7 ::\,ATIVE PAY}1E-"1T :lIODELs.-The Secretary shall de8 velop [and annually revic,,' and update?] Alternative 

9 Payment Models to be applied under this subsection. 

10 "(4) APPRovAL OF PROPOSED A1IrER-"1ATl\,}~ 

11 PADIE-"1T :lIODELS.-The Secretary shall develop a 

12 process b~T which physicians, medical societies, health 

13 care provider organizations, and other entities may 

14 propose Alternatiye Payment Models for consider15 ation [for approval by the Secretary to apply under 

16 this subsection?].". 

17 (c) REPORTS 0-"1 l\10DIFIED PFS SYSTEM A.'JD PAY18 l\lE::\,T SYS'l'EM AL'l'ER::\,ATl\,}]S.-

19 (1) BL\-"1::\,VAL PROGRESS REPORTS BY SE(,-

20 RELillY.-Not later than [--] , and evcry 6 

21 months thereafter, the Secretary of Health and 

22 Human Senlces shall submit to Conb'Tess and post 

23 on the public Internet website of the Centers for 

24 Medicare & Medicaid Senlces a biannual progress 

25 report on the implementation of the update iucentiw 

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[DIB( TSSIO:"l' DRA}'T] 

22 

program under section 1848A of the Social Security 

2 Act, as added by subsection (b)(2). Each such report 

3 shall inelude an evaluation of such update incentive 

4 program and recommendations ,vith respect to such 

5 program and appropriate update mechanisms. 

6 (2) GAO AXD MEDPAC REPORTS.-

7 (A) GAO REPORT OX IXlTIAL STAGES OF 

8 PROGRAM.-Not later than [--] , the Comp9 troller General of the United States shall sub10 mit to Congress a report anal~Tzing the e)"i:ent 

11 to which such update incentive program under 

12 section 1848A of the Social Security Act, as 

13 added by subsection (b)(2), as of such date, is 

14 

15 

16 

17 

18 

19 

20 

21 

22 

23 

24 

25 

f:\ VHLC\0528 13\052813.001.xml 

May 28, 2013 (8:38 a.m.) 

successfully satisf}ing [performance objectives], including \\ith respect to-

(i) the process for developing and selecting quality measures and apprO\ing 

quality measure sets [, including updates 

and modifications,] under subsection[s] 

(b) [and (e)] of snch section 1848A; 

(ii) the pr()(;ess for assessing performanee against such llWasures and sets under 

subsection (el) of such section; and 

(iii) the adequacy of the measures and 

sets so selected and approved. 

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85440.023

F:IPIH13ICMS\MEDCR\ECRISGR-EC 10XML 

[DlSCFSSIO:\' DRAFT] 

23 

(B) EVALUATIOX BY GAO A.'\'D lIIEDPAC 0.:-1 

2 Il\IPLE:\IEXTATIO.:-1 01<' PIL\8E II.-The Comp3 troller General and the Medicare Payment Adyi4 sory Commission shall each evaluate the initial 

5 phase of the update incentive program under 

6 such section 1848A and shall submit to Con7 6'Tess, not later than [ __ ], a report with rec8 ommendations for imprm'ing such update iuce]]-

9 tiYe program. 

10 (3) SECHwrARIAL HEP()HT 0.:-1 PADTE1'T 81'8-

12 (A) 11' GEKERAL.-Not later than [--] , 

13 the SecretaD- of Health and Human Sen'ices 

14 shall submit to COllgTess a report that analyzes 

15 multiple options for alternative payment models 

16 [under]/[to]/[in lieu of] section 1848 of the 

17 Soeial Security Act (42 U.S.C. 1395w-4). In 

18 analyzing such models, the Secretary shall ex19 amine at least the follo,,'illg' models: 

20 (i) Aeeountable eare organization pay21 mellt models. 

22 (ii) Primary eare medical home pay23 ment models. 

24 (iii) Bundled or episodic paynlents for 

25 certain conditions and sen-ices. 

f:WHLCI0528131052813.001.xml (55050114) 

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26 


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lD1!s(TSSIO~ DRAFT] 

24 

(iv) Gainsharing' arrallg·ements. 

2 (B) ITE1\lS TO BE I:\CIXDED.-Such report 

3 shall include information on how each 1'ec4 olllmended new payment model "ill achieve 

5 ma.~mum flexibility to reward high quality, effi6 cicnt care. 

7 (4) TRACKIXG E}"l'E:\DITURE GRO,YTH AI\D AC8 cEss.-Beginning in [--] , the Secretary shall 

9 track expenditure gTowth and beneficiary access to 

10 physicians' services under section 1848 of the Social 

11 Security Act (42 U.S.C. 139i')w-4) and shall post on 

12 the public Internet website of the Centers for Medi13 care & Medicaid Services annual reports on such 

14 topics. 

f:WHLCI0528131052813.001.xml 

May 28, 2013 (8:38 a.m.) 

(55050114) 
27 

Mr. PITTS. This discussion draft took into account the conversations and work of the Energy and Commerce majority and minority 

staffs, as well as the long collaborative relationship we have had 

with the Ways and Means Committee. 

It was also not a complete reform proposal. Rather, it was designed to be a partial release that allows for input from stakeholders and members of this committee. Again, we are seeking substantive feedback on ways to complete this draft, and I would encourage all interested parties to submit their comments to the committee by June 10th. 

The committee has sought to accomplish SGR reform through an 

open and transparent process with consideration given to all relevant stakeholders. To briefly summarize the draft legislation, 

Phase I repeals the SGR formula and provides a period of payment 

stability. During this time, providers will work with the Secretary 

to identify quality goals and methods of measurement. Phase II 

will build upon the work of Phase I, tying quality measurement to 

fee-for-service payment. Provider input will be essential to defining 

quality medicine during Phases I and II. Any time throughout 

Phase I and II providers may voluntarily opt out of fee for service 

by participating in an alternate payment model. 

These models will be flexible. Some exist today, such as medical 

homes, while new and innovative models may also be created and 

adopted. Some specifics, such as the duration of payment stability, 

or the methods of assessing providers on quality measures, have intentionally been left open in our discussion draft. We look forward 

to input on these and other topics from today’s witnesses and the 

stakeholder community at large with the goal of achieving meaningful Medicare payment reform and designing the best possible 

system for patients and providers alike. 

From the beginning of this process, there has been one clear goal: 

to remove the annual threat of looming provider cuts by permanently repealing the flawed SGR and replacing it with a system 

that incentivizes quality care, not simply volume of services. If we 

are to succeed in getting reform to the President’s desk during this 

Congress, reform must be bipartisan and bicameral. It must also 

be fully offset and fiscally responsible. However, we are not making 

the mistake that has sidelined SGR in years past by having the 

pay-for discussion before we know what we are paying for. 

The commitment to exploring bipartisan reform from Mr. 

Pallone, Mr. Waxman, leaves me hopeful that bipartisan reform is 

indeed possible. In addition, our longstanding and continuing relationship with Chairmen Camp and Brady from the Ways and 

Means Committee underscores the commitment that the House has 

to reforming SGR this Congress. I look forward to working with all 

parties in the coming weeks and months with the goal of getting 

SGR reform to the President’s desk. And I look forward to hearing 

the views and opinions of our witnesses today, and I would like to 

thank each of them for appearing before this subcommittee. 

Thank you. And I yield the balance of my time to the vice chair, 

Dr. Burgess. 

[The prepared statement of Mr. Pitts follows:] 

28 

PREPARED STATEMENT OF HON. JOSEPH R. PITTS

The Subcommittee will come to order. 

The Chair will recognize himself for an opening statement. 

On February 7 and April 3, 2013, the Energy and Commerce and Ways and 

Means Committee Republicans released three-phase outlines for permanently repealing the Sustainable Growth Rate (SGR) and moving toward a Medicare reimbursement system that rewards quality over volume. Stakeholder feedback followed 

each release and has been integral to the development of this policy, culminating 

in the draft legislative framework released on May 28th. 

This discussion draft took into account the conversations and work of the Energy 

and Commerce majority and minority staffs, as well as the long collaborative relationship we have had with the Ways and Means Committee. 

It is also not a complete reform proposal. Rather, it was designed to be a partial 

release that allows for input from stakeholders and members of this committee. 

Again, we are seeking substantive feedback on ways to complete this draft, and 

I would encourage all interested parties to submit their comments to the Committee 

by June 10th. 

The Committee has sought to accomplish SGR reform through an open and transparent process, with consideration given to all relevant stakeholders. 

To briefly summarize the draft legislation, Phase 1 repeals the SGR formula and 

provides a period of payment stability. 

During this time, providers will work with the Secretary to identify quality goals 

and methods of measurement. 

Phase 2 will build upon the work of Phase 1, tying quality measurement to fee 

for service payment. Provider input will be essential to defining quality medicine 

during Phases 1 and 2. 

Any time throughout Phases 1 and 2, providers may voluntarily opt-out of fee-forservice by participating in an alternate payment model. These models will be flexible. Some exist today, such as medical homes; while new and innovative models may 

also be created and adopted. 

Some specifics, such as the duration of payment stability or the methods of assessing providers on quality measures have intentionally been left open in our discussion draft. We look forward to input on these and other topics from today’s witnesses and the stakeholder community at large, with the goal of achieving meaningful Medicare payment reform and designing the best possible system for patients 

and providers alike . 

From the beginning of this process, there has been one clear goal: to remove the 

annual threat of looming provider cuts by permanently repealing the flawed SGR 

and replacing it with a system that incentivizes quality care, not simply volume of 

services. If we are to succeed in getting reform to the President’s desk during this 

Congress, reform must be bipartisan and bicameral. It must also be fully offset and 

fiscally responsible. However, we are not making the mistake that has sidelined 

SGR in years past by having the pay-for discussion before we know what we are 

paying for. 

The commitment to exploring bipartisan reform from Mr. Pallone and Mr. Waxman leaves me hopeful that bipartisan reform is indeed possible. In addition, our 

long standing and continuing relationship with Chairmen Camp and Brady from the 

Ways and Means committee underscores the commitment that the House has to reforming SGR this Congress. I look forward to working with all parties in the coming 

weeks and months with a goal of getting SGR reform to the President’s desk. 

I look forward to hearing the views and opinions of our witnesses today, and I 

would like to thank each of them for appearing before the Subcommittee. 

Thank you, and I yield the balance of my time to Rep. 

——————————————————. 

Mr. BURGESS. Thank you, Mr. Chairman. 

This hearing is all about momentum. For 10 years I have been 

here in this committee. On both sides of the dais we have all 

agreed that the SGR needs to go, and then we get to hear from 

some really smart people from Washington think tanks to tell us 

what the brave new world should look like, and then nothing happens. And we all pat ourselves on the back because we agree that 

the Sustainable Growth Rate makes some unrealistic assumptions 

about spending inefficiency, but really doesn’t move the needle. 

29 

Now, this morning, in spite of what you read in the newspapers, 

today is different. It is different in two respects. First, last week 

the committee released the first draft of legislative language to 

eliminate the SGR and move Medicare to a program that more 

aligns with the private sector in both model development and linking payment to quality. The draft continued the trend of soliciting 

more provider feedback than at any point in history, and I pledge 

to all Medicare providers that your feedback, if provided to the 

committee, accompanied by helpful guidance, will be given the full 

attention of the committee, and we will work with you. 

Yes, this is a first draft, a very rough first draft. Nothing is sacrosanct except the original paragraph which repeals the Sustainable Growth Rate formula. We have got to catch Medicare up with 

what is happening in the real world. We have to allow every practice modality that is out there to flourish. Yes, that includes fee for 

service. But we have got to catch up with what is happening in the 

real world, and that is what this morning’s hearing is all about. 

I thank the chairman for calling the hearing, and I will yield 

back the balance of my time. 

Mr. PITTS. The chair thanks the gentleman. 

And now turns to the gentlelady from the Virgin Islands, Dr. 

Christensen, who is filling in for the ranking member today. Recognized for 5 minutes. 

OPENING STATEMENT OF HON. DONNA M. CHRISTENSEN, A 

REPRESENTATIVE IN CONGRESS FROM THE VIRGIN ISLANDS 

Mrs. CHRISTENSEN. Thank you, Mr. Chairman, and I want to 

thank you and Ranking Member Pallone, who had to return home 

for the funeral of our beloved Senator Lautenberg, for holding this 

hearing today. We have come together many times to discuss this 

issue, and I hope that today’s discussion finally puts us on a path 

to real and broadly implementable solutions that focus on quality, 

improved patient outcomes, fairer provider reimbursement, efficiency, and lower cost. 

Replacement of Medicare’s SGR payment system is something 

that we all agree needs to happen. And I think we also all agree 

that the healthcare delivery system itself is dysfunctional. It, too, 

needs to be fixed, and several provisions in the Affordable Care 

Act—to pilot new payment models and models of care, to innovate 

and to help guide the best treatments—can both improve care, help 

us to reform and replace the current payment system, and lower 

costs. 

As a family physician, the concept of medical home is not a foreign one to me. And as a community health doctor in the public 

sphere in a small community I know the value of teamwork to patient outcome, as well as satisfaction. But because the system was 

not set up to support a team approach, it added time and efforts 

that could have better been spent caring for more patients, enhancing our knowledge, or quality time with our family. 

We are fortunate that some healthcare providers and systems 

have begun to do the reforms we are attempting to create nationally through the Affordable Care Act and that they can share their 

journeys’ successes and recommendations, based on experience 

30 

with us today, and I want to thank the panelists for being here, 

and I look forward to their testimonies. 

As we highlighted in our last hearing on this issue, innovation 

is key to improving healthcare delivery and payment system. However, moving forward it is important for us to encourage innovation 

while also ensuring that the benefits of innovation reach all communities. Historically, innovation in health care has improved outcomes for those who are insured or are more affluent much faster 

than for those who are low income or uninsured, exacerbating existing health disparities. 

It is also important that the efforts to reform and replace the 

SGR take into account those providers who currently work in communities and treat patients who have long been underserved by the 

health system. These patients are adversely affected by many social determinants of health, have less reliable access to quality 

care, and ultimately suffer poorer health outcomes as a result. I 

look forward to hearing how pay for performance and value or outcome-based reimbursement can address this particular concern. 

Today, we have a lot to focus on, as the background memo for 

this hearing indicates. My colleagues on the other side of the aisle 

have released two sets of draft frameworks, together with their colleagues on Ways and Means. They have also released draft legislative language, and this hearing is intended to get feedback on the 

legislative language released and, more importantly, to help inform 

our Members on the committee process moving forward. And there 

are some gaps that this hearing I think can probably help to fill. 

I also look forward to working with my colleagues on this and the 

Ways and Means Committee, and other colleagues, as well as the 

provider and patient advocacy organizations, to continue the efforts 

of our panelists and others and those of the Affordable Care Act for 

reform. Our Medicare patients need and deserve it. 

Is there anyone who would like the balance of my time? And if 

not, Mr. Chairman, I will yield back. 

Mr. PITTS. The chair thanks the gentlelady. 

Now recognize the chair of the full committee, Mr. Upton, 5 minutes for opening statement. 

OPENING STATEMENT OF HON. FRED UPTON, A REPRESENTATIVE IN CONGRESS FROM THE STATE OF MICHIGAN 

Mr. UPTON. Thank you, Mr. Chairman. 

You know, today we are building upon the significant progress 

that the committee has made during the past couple years and 

take a very important step in permanently repealing the flawed 

Sustainable Growth Rate, otherwise known as SGR or the doc fix. 

The legislative framework that we released last week, the review 

of which is the purpose of our hearing today, includes invaluable 

feedback from so many stakeholders. 

However, this legislative framework is not etched in stone. And 

rather, it is an opportunity for the committee to continue working 

closely with Members and stakeholders towards a permanent repeal of SGR. It also doesn’t contain a pay-for, as we intend to avoid 

the error made in years past of discussing how to pay for reform 

before the policy is actually developed. But make no mistake, SGR 

31 

reform will be offset with a real and responsibly paid-for item when 

it comes to the floor of the House for a vote. 

When Chairman Camp and I began the push towards reform earlier this year and in the last Congress, it was with common purpose and mutual support. Our friendship and working relationship 

have never been stronger. Both committees, working closely together and with careful attention to public input, have been able 

to transform the initial February outline that we jointly released 

into a solid policy framework. There remains much more work to 

be done for sure, including the hope for bipartisanship, but we 

would not be where we are today without our good friends on the 

Ways and Means Committee, and that collaborative effort will continue. 

Over the past several weeks Energy and Commerce Republicans 

and Democrats have labored hand-in-hand to explore whether bipartisan reform might be possible. And while the release last week 

was done without their names attached, the language it contained 

did reflect our talks and collaborative efforts with committee Democrats. I want to particularly thank Mr. Waxman and Pallone for 

their leadership and continued interest in exploring SGR reform. 

And while we stand today at a point far beyond any reform efforts of the past, much work still remains. SGR is one of the most 

complex issues confronting the Congress and, not surprisingly, difficult policy questions remain to be answered. Today’s testimony 

will help answer some of those questions. 

The committee has been dedicated to making reform a transparent process. Such transparency has already given this committee insightful recommendations from multiple stakeholders that 

culminated in the legislative release last week. We look forward to 

continuing that process in the weeks to come. 

So SGR reform is vital to ensuring economic stability for physicians, access to care for seniors, securing the future of the Medicare 

system. I want to conclude by sharing my sincere optimism that, 

in fact, we will achieve a bipartisan bill, one that represents the 

work of both sides of the aisle, and in the end the best chance for 

SGR reform to work its way to the President’s desk is through that 

bipartisanship. 

So let’s not be satisfied with the unprecedented progress that we 

have already made. Let’s continue working until we have solved 

the problem for not only our physicians, but certainly for our seniors. 

And I yield the balance of my time to Dr. Cassidy. 

[The prepared statement of Mr. Upton follows:] 

PREPARED STATEMENT OF HON. FRED UPTON

Today we build upon the significant progress this committee has made during the 

past couple years and take an important step in permanently repealing the flawed 

Sustainable Growth Rate, otherwise known as SGR. 

The legislative framework we released last week, the review of which is the purpose of our hearing today, includes invaluable feedback from many stakeholders. 

However, this legislative framework is not etched in stone. Rather, it is an opportunity for this committee to continue working closely with members and stakeholders and toward a permanent repeal of SGR. 

It also does not contain ‘‘pay-fors’’ as we intend to avoid the error—made in years 

past—of discussing how to pay for reform before the policy is developed. But make 

32 

no mistake, SGR reform will be offset with a real and responsible pay-for when it 

comes to the floor of the House of Representatives for a vote. 

When Chairman Camp and I began the push toward reform earlier this year, it 

was with a common purpose and mutual support. Our friendship and working relationship have never been stronger. Both committees, working closely together and 

with careful attention to public input, have been able to transform the initial February outline we jointly released into a solid policy framework. There remains much 

more work to be done, including the hope for bipartisanship, but we would not be 

where we are today without our great friends on the Ways and Means Committee. 

That collaborative effort continues. 

Over the past several weeks, Energy and Commerce Republicans and Democrats 

have labored, hand-in-hand, to explore whether bipartisan reform might be possible. 

While the release last week was done without their name attached, the language 

it contained did reflect our talks and collaborative efforts with committee Democrats. I would like to thank Ranking Members Waxman and Pallone for their leadership and continued interest in exploring SGR reform. 

While we stand today at a point far beyond any reform efforts of the past, much 

work remains to be done. SGR is one of the most complex issues confronting the 

Congress, and not surprisingly, difficult policy questions remain to be answered. Today’s testimony will help answer some of those questions. 

The committee has been dedicated to making reform a transparent process. Such 

transparency has already given this committee insightful recommendations from 

multiple stakeholders that culminated in the legislative release last week. We look 

forward to continuing that process in the weeks to come. 

SGR reform is vital to ensuring economic stability for physicians, access to care 

for seniors, and securing the future of the Medicare system. I would like to conclude 

by sharing my sincere optimism that we will achieve a bipartisan bill, one that represents the work of Republicans and Democrats. In the end, the best chance for SGR 

reform to work its way to the President’s desk is bipartisanship. Let’s not be satisfied with the unprecedented progress that we have made—let’s continue working 

until we have finally solved this problem for our doctors and our seniors. 

Thank you, and I yield the balance of my time to Rep. 

——————————————————. 

Mr. CASSIDY. Thank you Mr. Chairman. 

The recent CBO projection reducing the cost of repealing the 

SGR to $138 billion gives us an opportunity to reform this flawed 

payment formula. We should see this and provide reform that puts 

us on a financially sustainable path, incentivizing quality health 

care to individuals and certainly to physicians. I think we all agree 

on that. 

In this process we must be careful to not sacrifice the independence and autonomy of the independent physician practice, and as 

a doc I am very sensitive to that. Mr. Chairman, I have working 

on a proposal that would ensure the independent physician and the 

small group is protected. I will be discussing it during my questions, and hope we can work together as we move forward with reform. 

In addition, I would like to commend the chairman for including 

a process for alternative payment models in the committee discussion draft. I understand that this is an issue the chairman wishes 

to further develop. I fully support this approach, and, again, I look 

forward to working with the committee to develop it further. 

I yield back to Mr. Upton or to Dr. Gingrey. 

Mr. GINGREY. Dr. Cassidy, thank you for yielding. 

Mr. Chairman, as a physician, I am pleased and excited that we 

are at this moment today. We are addressing the flawed SGR system, seeking to give doctors more certainty over reimbursement. By 

using specialty societies and other professional groups to create 

quality measures that will be used to promote best practices, we 

33 

will see better patient outcomes and a more efficient—a much more 

efficient payment system. 

I do have a concern that the quality measures associated with 

payment reform may lead to unwarranted court claims. Government payment reform should not have any effect on a doctor’s liability. During debate, then Chairman Waxman submitted comments for the record which stated that it was not the intent of the 

President’s healthcare bill to, quote, ‘‘create any new actions or 

claims based on the issuance or implementation of any guideline or 

other standard of care,’’ end quote. Nor is it to supercede, modify, 

or impair any State medical liability law governing legal standards 

or procedures used in their medical malpractice cases. 

Mr. Chairman, there is bipartisan agreement that the intent of 

our Federal healthcare laws is to promote quality, not to create 

new avenues for medical malpractice claims. I look forward to 

working with the subcommittee to address this potential loophole 

as we work toward physician payment reform. 

Thank you for your indulgence, and I yield back. 

Mr. PITTS. The chair thanks the gentleman. 

That concludes the opening statements. We have one panel 

today. I will introduce our panel at this time. 

First of all, Dr. Cheryl Damberg, senior policy researcher and 

professor of the Pardee RAND Graduate School. Secondly, Mr. William Kramer, executive director for national health policy, Pacific 

Business Group on Health. Thirdly, Dr. Jeffrey Rich, immediate 

past president of the Society of Thoracic Surgeons, director at 

large, Virginia Cardiac Surgery Quality Initiative. And finally, Dr. 

Thomas Foels, executive vice president and chief medical officer, 

Independent Health. 

Thank you all for coming. You will each have 5 minutes to summarize your testimony. Your written testimony will be placed in 

the record. 

Dr. Damberg, you are recognized for 5 minutes for your opening 

statement. 

STATEMENTS OF DR. CHERYL L. DAMBERG, PH.D., SENIOR 

POLICY RESEARCHER, PROFESSOR, PARDEE RAND GRADUATE SCHOOL; WILLIAM KRAMER, EXECUTIVE DIRECTOR 

FOR NATIONAL HEALTH POLICY, PACIFIC BUSINESS GROUP 

ON HEALTH; JEFFREY B. RICH, M.D., IMMEDIATE PAST 

PRESIDENT OF THE SOCIETY OF THORACIC SURGEONS, DIRECTOR AT LARGE, VIRGINIA CARDIAC SURGERY QUALITY 

INITIATIVE; AND THOMAS J. FOELS, M.D., M.M.M., EXECUTIVE 

VICE PRESIDENT, CHIEF MEDICAL OFFICER, INDEPENDENT 

HEALTH 

STATEMENT OF CHERYL L. DAMBERG 

Ms. DAMBERG. Thank you for inviting me here today. As the committee considers ways to revise the physician fee schedule so that 

payment policy supports the delivery of high quality, resource-conscious health care, there are important design features related to 

structuring performance-based incentive programs that I want to 

call to your attention. Thoughtful incentive design can ease the 

transition process for both physicians in the Medicare program and 

34 

enhance the likelihood of program success. Due to limited time I 

will touch on only a few of the important design issues. More details can be found in my written testimony. 

First, encourage improvement among all physicians by using a 

continuous payment incentive approach. A continuous incentive approach pays physicians additional incentive payments for each increment of improvement they achieve. A continuous approach 

avoids the cliff effects that are common in incentive structures that 

tie payments to a single all-or-nothing cut point, setting up a large 

number of providers who will receive nothing despite making actual improvements and investments to improve. Paying more per 

increment of improvement at the beginning and the middle part of 

the continuum than toward the top strengthens incentives to physicians at the lower end who are making investments to improve. 

Second, use fixed performance thresholds to make it clear in advance to physicians what level of performance is required to 

achieve an incentive. Over the last decade many performance-based 

incentive programs used tournament-style relative thresholds that 

create a competition among providers. Relative thresholds create a 

great deal of uncertainty and can lessen the response to the incentive, particularly for those physician who are a distance from the 

anticipated threshold. Instead, physicians should compete against 

a fixed national benchmark where all who improve and hit the designated targets win. Avoiding competition between physicians for a 

limited number of winning positions will help to foster sharing of 

best practices among physicians. 

Third, make payments meaningful to generate the desired response. The experiments of the last decade in pay for performance 

generally found weak results in part because incentive payments 

were relatively small, on the order of 1 percent. Physician leaders 

indicate that incentives of 5 to 10 percent are required to be meaningful. In the beginning, while physicians are learning how to participate, incentives could be relatively modest. However, over time, 

and in the near term, rather than the long term, the size of the 

incentives should be increased. 

Begin the transition now for primary care by leveraging measures used in Medicare Advantage and other private payer programs. Much work has gone on over the past decade to advance the 

development of performance measures, particularly for care delivered by primary care physicians. These measures have been widely 

deployed by private payers, Medicaid agencies, and Medicare in the 

context of performance measurement, accountability, and incentives, both in managed care and fee for service. The committee and 

Congress need to understand that a majority of primary care physicians in the United States have already been exposed to these programs. And they could start by working with the Medicare Advantage star rating program and in the process align measurement activities already targeting ambulatory providers. 

Fifth, for many clinical subspecialties measures are completely 

lacking or few are available that could be readily deployed. As 

such, concerted effort and Federal investment is needed to develop 

and bring measures to market. CMS should identify and focus development efforts on 10 to 12 clinical subspecialty areas that contribute to a significant portion of Medicare spending and utilizaVerDate Nov 24 2008 11:36 Dec 03, 2013 Jkt 037690 PO 00000 Frm 00040 Fmt 6633 Sfmt 6633 F:\MY DOCS\HEARINGS 113\113-50 CHRIS
35 

tion, and they should work with measure development experts and 

clinical specialties to identify performance gaps and develop those 

measures. 

Sixth, allow physicians to opt out if they can demonstrate that 

they have moved to other value-based purchasing models that 

incentivize cost and quality. Some providers have already started 

to migrate toward alternative payment models such as ACOs, bundled payments, and medical homes. To the extent that these models contain performance-based incentives for cost and quality they 

should be considered acceptable opt-out arrangements. For physicians who do not participate in new payment models, they should 

minimally demonstrate that they are able to perform parallel functions to deliver high-quality, efficient care. 

Seventh, rather than simply imposing this change on physicians, 

Medicare should work in partnership with physicians to support 

their improvement. Creating an environment where physicians can 

succeed should include such things as building support structures 

with local community partners to work on improvement and redesign, facilitating sharing of best practices and learning networks, 

providing meaningful, timely data feedback, and continuing to advance the health IT infrastructure. 

In summary, the ability to move successfully forward with new 

performance-based payment models is predicated on having a robust set of measures, a good incentive design, and a support structure that can help physicians participate and succeed in the program. Thank you for the opportunity to appear here today, and I 

would be happy to take your questions. 

Mr. PITTS. The chair thanks the gentlelady. 

[The prepared statement of Ms. Damberg follows:] 

36 


85440.025

Testimony 

Physician Payment Reform 

Designing a Performance-based Incentive Program 

Cheryl L. Damberg 

RAND Office of External Affairs 

CT-389 

June 2013 

Testimony presented before the House Energy and Commerce Committee, Subcommittee on Health on June 5, 2013 

This product is part of the RAND Corporation testimony series, RAND testimonies record testimony presented by RAND associates 

to federal, state, Of local legislative committees; government-appointed commissions and panels; and private review and oversight 

bodies. The RAND Corporation is a nonprofit research organization providing objective analysis and effective solutions that address 

the challenges facing the public and private sectors around the world. RAND's publications do not necessarily reflect the opinions of 

its research clients and sponsors. RAN O® is a registered trademark. 
37 


85440.026

Published 2013 by the RAND Corporation 

1776 Main Street, P.O. Box 2138, Santa Monica, CA 90407-2138 

1200 South Hayes Street, Arlington, VA 22202-5050 

4570 Fifth Avenue, Suite 600, Pittsburgh, PA 15213-2665 

RAND URL: http://www.rand.org/ 

To order RAND documents or to obtain additional information, contact 

Distribution Services: Telephone: (310) 451-7002; 

Email: order@rand.org 
38 


85440.027

Cheryll. Damberg' 

The RAND Corporation 

Physician Payment Reform: 

Designing a Performance-based Incentive Program2 

Before the Committee on Energy and Commerce 

Subcommittee on Health 

House of Representatives 

June 5, 2013 

Chairman Pitts, Ranking Member Pallone, and distinguished Members of the Subcommittee, 

thank you for inviting me here today. My name is Cheryl Damberg and I am a senior health 

policy researcher at the RAND Corporation. I appreciate the opportunity to appear before you to 

discuss physician payment reform. As you work to shift physician payment policy from one that 

currently incentivizes the delivery of more services without regard to quality or outcomes to a 

payment policy that incentivizes the delivery of high quality, resource conscious (i.e., high value) 

health care, there are a number of important design elements that I ask you to consider. The 

lessons draw from the experiences of both public and private sector payers who over the last 

decade have implemented performance measurement and performance-based incentive 

systems. Thoughtful incentive design can ease the transition process for both physicians and 

the Medicare program, provide a robust, credible system of measurement that will serve as the 

basis for determining who receives incentive payments and how they receive them, and 

enhance the likelihood of program success-all of which serves the ultimate goal of improving 

care for Medicare beneficiaries. My comments derive from research I have conducted 

examining the use of financial incentives tied to performance and my experience working with 

provider organizations over the past decade to measure health care quality and costs. 

As highlighted in testimony that I gave to this committee in February (Damberg, Cheryl L., 

"Efforts to Reform Physician Payment: Tying Payment to Performance," testimony presented 

before the House Energy and Commerce Committee, Subcommittee on Health, February 

14,2013. As of May 28,2013: http://www.rand.org/pubs/testimonies/CT381), performancebased incentive models (also referred to as pay for performance or value-based payment 

(VBP))-which tie payments to performance on a set of defined quality and cost measures-are 

relatively new to the health system and represent a work in progress. It is vitally important to 

1 The opinions and conclusions expressed in this testimony are the author's alone and should not be 

interpreted as representing those of RAND or any of the sponsors of its research. This product is part of the 

RAND Corporation testimony series. RAND testimonies record testimony presented by RAND associates to 

federal, state, or local legislative committees; government-appointed commissions and panels; and private 

review and oversight bodies. The RAND Corporation is a nonprofit research organization providing objective 

analysis and effective solutions that address the challenges facing the public and private sectors around the 

world. RAND's publications do not necessarily reflect the opinions of its research clients and sponsors. 

2 This testimony is available for free download at http://www.rand.org/pubs/testimonies/CT389.html. 
39 


85440.028

signal to providers what patients and payers expect them to be working towards in terms of 

delivery of appropriate care and care that helps achieve the best outcomes for patients. Explicit 

measures-when tied to payment-help focus and redirect physicians and the organizations in 

which they work towards redesigning care processes and how they coordinate actions with 

other care providers in order to deliver better value. Value is defined as the outcomes (outputs) 

achieved divided by the cost or resources used (inputs) to generate those outcomes. 

By linking payment to performance, value-based payment programs seek to incentivize 

providers to innovate and redesign care delivery to drive improvements in quality and how 

resources are used (i.e., costs). Including costs as part of what is measured and how providers 

are paid is critical to ensure that services are efficiently delivered. Physicians who make 

decisions about treatments have a central role to play in helping to ensure that health care 

remains affordable for patients and other entities (employers, government agencies) that pay for 

care. The current fee-for-service (FFS) system used in Medicare to pay physicians contains 

incentives to the opposite effect. I will return to this issue at the close of my testimony. 

Designing a performance-based incentive program is a complex undertaking and how it is 

designed will determine the likelihood of its success. I will touch on several of the central design 

features that are important for you to consider. 

(1) Structure of Payment Incentives: There are several elements that comprise an "incentive 

payment structure," including whether providers are paid for attainment or improvement or both, 

the performance thresholds used to determine who gets paid, the form of the incentive (e.g., 

bonuses, shared savings, or penalties\ and the size of the incentive. Each of these, depending 

on how structured, can lead to different responses by providers. Below I comment on several of 

these elements and the approaches that will likely yield the desired result. 

a. Pay for improvement along the gradient: Medicare should pay providers using a 

continuous payment incentive approach so as to incentivize improvement along the continuum 

of performance. A continuous payment approach is used by Blue Cross Blue Shield of 

Massachusetts in its Alternative Quality Contract.4 In the case of the Alternative Quality Contract 

(AQC), providers receive a bonus ranging from 2% to 10% of per member per month payments 

depending on where they are on the performance distribution. Providers receive additional 

payouts for each increment of improvement--they are paid along the continuum once they hit a 

3 Penalties (Le., downside risk) are not favored by providers. They tend to be used to discourage 

actions/outcomes that should not occur such as hospital acquired infections which can be prevented. 

4 Song et al.. Health Care Spending and Quality in Year 1 of the Altemative Quality Contract. NEJM. 

365:10. September 8, 2011. 

2 
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85440.029

minimum threshold of performance. This approach avoids the "cliff' effects that are common in 

payment structures that tie payments to a Single all or nothing cut point (such as having to hit 

the 75th percentile of performance among providers); all or nothing payment structures set up a 

large number of providers who will receive nothing despite the fact that they are making 

improvements and making investments to improve. In the AQC model, the formula that 

translates each increment of improvement into payment incentivizes improvement at the 

beginning and middle of the continuum more than toward the top part of the distribution. This 

approach acknowledges that providers at the lower end of the performance distribution likely 

need to make more substantial investments to achieve quality improvement than providers who 

move from 95% to 98% performance. 

b. Use fixed thresholds: Over the last decade, many performance-based incentive programs 

used relative thresholds that were only known to providers after the close of the performance 

measurement period.5 While this "toumament style" approach incentivizes continued 

improvement because the target moves as the entire group of providers improve, it creates a 

great deal of uncertainty for providers and can lessen the response to the incentive, particularly 

for those providers who are a distance from the anticipated threshold. The incentive structure 

should establish fixed performance targets that remain stable over some time period. This will 

help providers understand what level of performance they need to achieve to secure incentive 

payments and it will send a clear signal about performance expectations. Providers should 

compete against a national benchmark rather than a moving target based on relative 

comparisons of performance. This will establish an environment where all providers who 

improve and hit the designated targets win; because there isn't a competition between providers 

for a limited number of winning positions, this will help to foster the sharing of best practices 

among providers. One approach to setting targets that is used in the Alternative Quality 

Contract is to use empirically derived cut points based on the data.s Another approach is to use 

national benchmarks-such as the National Committee for Quality Assurance's (NCQA) Health 

Ernployer Data Inforrnation Set (HEDIS) measure benchmarks. The highest level benchrnark 

can be set for what is best in class and is achievable, based on the actual performance of peer 

specialty physicians. 

c .. Make payments meaningful: In the beginning, while physicians are learning how to 

participate in the incentive prograrn (learning how to collect/capture the data and subrnit the 

5 For example, physicians who might receive a bonus payment in 2013 based on their 2012 calendar year 

performance would not know the threshold for winning (say the 75th percentile cutpoint) until May of 2013 

once scores are in for all physicians. 

6 Safran, DG et al. Evaluating the Potential for an Empirically-derived Standard of Performance Excellence 

in Ambulatory Patient Care Experience Measures: Analysis in Support of NCQA 's Efforts to Develop a 

Physician Recognition Program in Patient-Centered Care. October 2007. 

3 
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85440.030

information and redesigning care processes to improve), incentives could be relatively modest; 

however, over time (and in the nearer rather than longer term), bonuses should be increased. 

Incentives on the order of 5% to 10% of pay are required to change the behavior of physicians. 

The experiments of the last decade in the area of pay for performance generally found weak 

results, in part, because incentives were relatively small (on the order of 1 %). I have conducted 

interviews with physician leaders who have indicated that incentives of 5% to 10% are required 

to be meaningful. 

(2) Quality Measurement Infrastructure: Measures are the foundational element for 

determining payments under incentive-based payment models. While there are some measures 

ready to use, significant investments will need to be made over the next five years to develop 

and bring measures to market A concerted effort will need to be undertaken, by specialty area, 

to advance measure development; in the near term, CMS should identify and focus 

development efforts on 10-12 clinical subspecialty areas that contribute to a significant portion 

of Medicare spending and utilization (e.g., cardiology, gastroenterology, endocrinology, 

orthopedics, oncology). 

a. Leverage the measurement precedent in primary care: It is important to recognize that 

much work has gone on over the past decade to advance the development of performance 

measures-particularly for care delivered by primary care physicians (PCPs). These measures 

address preventive, acute, and chronic care areas and have been widely deployed by private 

sector payers and Medicaid agencies over the last decade in the context of performance 

measurement, accountability, and incentive programs-both on the managed care side and the 

PPO/FFS side. The Committee and Congress need to understand that a majority of PCPs in the 

United States have already been exposed to these performance measures and are familiar with 

the concept of pay for performance. Because these existing measures represent evidencebased practice and have been well tested, there is no reason that these should not be 

immediately deployed in the context of an incentive-based fee schedule within Medicare. For 

example, Medicare could start (and thereby align the measurement activities targeting 

ambulatory care providers) with existing measures used in the Medicare Advantage Star rating 

program. These measures are also the focus of the Physician Quality Reporting Initiative 

(PQRI), which will be the basis of the physician value-based payment modifier that will go into 

effect in 2015 as called for in the Affordable Care Act Therefore, PCPs could begin immediately 

reporting on a set of measures during the payment stability period, to gain experience with data 

capture and reporting and to receive benchmarking reports from Medicare to identify areas for 

improvement well in advance of transitioning to incentive payments. 

4 
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85440.031

b. Invest in measure development, particularly for clinical subspecialists. Efforts to 

develop measures for clinical subspecialists have lagged those addressing primary care. Some 

clinical specialties have taken steps-such as through the American Medical Association's 

Physician Consortium on Performance Improvement (PCPI)-to develop measures; however, 

for many clinical subspeclalties measures are completely lacking or there are few available 

measures that could be readily deployed. Recent efforts by the American Board of Intemal 

Medicine Foundation (ABIMF), in partnership with clinical specialty societies, have generated a 

list of more than 90 recommended areas to reduce the overuse of services.7 While not 

performance measures, these types of recommendations and clinical guidelines produced by 

specialty societies represent a starting place for identifying measure concepts that could be 

advanced for measure development. Substantial investment of resources is required to advance 

the development of measures for clinical subspecialties, and it will take several years (2.5 to 3 

years) from measure concept identification to having measures ready for deployment. 

c. Use a rigorous measure development process. Development of measures needs to occur 

using a scientifically rigorous process that is transparent, inclusive of physicians and other 

stakeholders, and ensures the reliability and validity of measures that become the basis of 

payment. Measure development is a science. It requires careful review of the scientific evidence 

to identify areas that define high quality care (which form the measure concept), vetting the 

evidence and concepts with clinical expert panels, specification of the concept using various data 

sources (e.g., claims data, electronic health records (EHRs)), field testing the measures across 

an array of providers with different data systems, assessing the measurement properties 

(reliability, validity of the measure), and finalizing the specification for uniform application across 

physicians in different settings. A model for development is the work that was conducted at RAND 

to develop the RAND Quality Assessment Tools (QA-Tools) and the ACOVE measures for the 

vulnerable elderly. (McGlynn et ai., 1995; Wenger et ai., 2003). Measures used in the incentive 

program should meet the scientific soundness criteria identified by the National Quality Measures 

Clearinghouse (NQMC).B These include the clinical logic (evidence supporting the measure is 

explicitly stated and strongly supported) and measure properties (i.e., reliability, validity, case-mix 

adjustment if appropriate). 

To expedite measure development in a cost-effective manner, measure developers should have a 

consortium of EHR data partners that will be test beds for rapid testing of electronic health record 

(i.e., e-Measure) concepts and alternative specifications at an early stage to identify the strongest 

7 Choosing Wisely: an initiative of the ABIM Foundation. 2012 [updated 2012; cited 2012 October 29th, 

2012]; Available from: http://choosingwisely.org/. 

B Agency for Healthcare Research and Quality. National Quality Measures Clearinghouse. 

http;/Iwww.qualitymeasures.ahrq.gov/tutoriallattributes.aspx 

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85440.032

candidates for full development. 

Because of the high stakes application of measures for payment and for driving provider 

performance, the measure development work should undergo a peer review process-meaning 

that the work of the measure developers and clinical panels should be published in clinical 

journals. Transparency of the process and underlying science will enhance the face validity of the 

process and the acceptability by the clinical community. 

d. eMS should establish a process where measure development experts work with clinical 

specialties to identify performance gap areas and work to develop those as measures. To 

engage providers to achieve the three aims of the National Quality Strategy, we must enlist them 

as true partners in defining the measures for which they will be held accountable as individuals, 

and more broadly, as care teams and systems of care. Physicians have a vitally important role to 

play in the selection of measure concepts, weighing the scientific evidence related to specific 

actions providers can take to influence the process or outcome, specifying measures (including 

how to adjust for differences in the patient populations they treat and which patients to exclude), 

assessing the feasibility of a measure in practice, and ultimately endorsing the measures once 

developed. Some physician specialty organizations have taken steps to identify measures and 

create registries containing process and outcome measures. These measures and data sources 

could provide a starting point. For example, the American College of Surgeons National Surgical 

Quality Improvement Program (ACS NSQIP®) generates validated, risk-adjusted, outcome 

measures to help surgeons improve the quality of surgical care. Prior to considering use of 

measures from specialty societies, the measures would need to meet the requirements of any 

measures-meaning that they are valid, reliable and evidence-based. 

e. Alignment and coordination is critical to reduce provider confusion and burden. 

Medicare has a number of existing measurement and payment incentive programs that target 

ambulatory care providers. These include Medicare Advantage, the Physician Quality Reporting 

System (PQRS), which will support the emerging physician value-based payment modifier 

program, and the meaningful use (MU) of EHRs incentive program. The requirements that are 

introduced within the reformed SGR incentive program for physicians need to coordinate and 

align with these efforts to avoid creating a more complex environment for physicians to navigate. 

For example, MU standards for EHRs could require that vendors support the capture of data 

elements needed to construct measures that will be used in the SGR and physician value-based 

payment modifier programs. 

6 
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85440.033

f. Build out the measure set to address other priority areas: The measures being used in 

the Medicare Advantage Star rating system that determine Quality Bonus Payments to plans, as 

well as those used by private payers, represent a starting place for the early phases of the 

incentive program implementation. However, Medicare will need to work collaboratively with 

clinical specialists and measure developers to address other important performance areas 

where performance measures are currently lacking-including access to care, care 

coordination, overuse of services/resource use, and patient outcomes (e.g., functioning, health 

status)). The areas for future measure development should consider the work of the National 

Quality Forum's National Priorities Partnership (NPP) and the Department of Health and Human 

Service's National Quality Strategy (Table 1), which have outlined key domains or areas where 

performance should be measured. Measure development for use in the context of the Medicare 

FFS incentive program should align with these areas. 

g. Promoting the delivery of high quality care means providing appropriate care and 

reducing the overuse of services. Development of efficiency measures is a national priority 

and these measures currently lag in development. While the concept of efficiency raises red 

flags of cost culling in the minds of physicians, physicians will focus on reducing the overuse of 

services when they understand that the desired action (whether it is shifting from a name brand 

drug to a generic or watchful waiting before advancing to imaging) is equivalent to the 

alternative, more costly approach to managing the patient or that the alternative, less desired 

action could lead to unnecessary harm. When measures of clinical overuse/misuse of services 

are supported by evidence, this will facilitate physician buy-in. 

Table 1 

National Quality Strategy's three aims: 

1. Better Care: Improve the overall quality of care, by making health care more patientcentered. reliable. accessible, and safe. 

2. Healthy People/Healthy Communities: Improve the health ofthe U.S. population by 

supporting proven interventions to address behavioral, social, and environmental 

determinants of health in addition to delivering higher-quality care. 

3. Affordable Care: Reduce the cost of quality health care for individuals, families, 

employers. and government. 

National Quality Strategy's six priorities: 

1. Making care safer by reducing harm caused in the delivery of care. 

2. Ensuring that each person and family are engaged as partners in their care. 

3. Promoting effective communication and coordination of care. 

4. Promoting the most effective prevention and treatment practices for the leading causes of 

mortality, starting with cardiovascular disease. 

5. Working with communities to promote wide use of best practices to enable healthy living. 

6. Making quality care more affordable for individuals, families, employers. and governments 

by developing and spreading new health care delivery models. 

7 
45 


85440.034

(3) Shifting to New Payment Models 

Some providers have already started to migrate towards alternative payment models such as 

accountable care organizations (ACOs), bundled payments that pay for pre-defined episodes of 

care, and medical homes. These payment models generally embed performance-based 

incentives into their structures and have pre-defined performance measures that must be met to 

receive shared savings or other types of incentive payments. ACOs require a certain size to 

enable providers to manage risk, and not all physicians will join ACOs. Primary care physicians, 

regardless of the size of their practice, can participate in medical homes, where they can earn 

extra dollars for managing patients at a high level of quality that can reduce the utilization of 

care in high cost settings such as emergency departments and hospitals. For some areas of 

care-such as an annual episode of diabetes or hip replacement surgery-specialists may be 

able to participate in bundled payment arrangements that provide a fixed fee with incentive 

payments tied to performance on quality measures (both process and outcome). All of these 

constitute value-based payment arrangements and should be considered acceptable opt-out 

arrangements to the extent that they address the Medicare population. The subset of physicians 

who do not participate in new payment models should minimally demonstrate they are able to 

perform parallel functions to deliver high quality, efficient care-such as connectivity to other 

providers (e.g., specialists, PCPs, hospitals) through health information exchange to better 

coordinate care, use of clinical decision support tools, and performance monitoring. 

(4) Uniqueness of Providers 

While there is diversity among physicians in where they practice (urban versus rural), their mix of 

patients (i.e., demographic and socioeconomic status (SES)), practice type, and specialty, it is 

important to remember that performance measures are "patient-driven." By that I mean that the 

measure defines what the patient needs, regardless of the type of physician practice where the 

patient is treated. Receipt of a flu shot should not be dependent on whether a patient is managed 

by a physician in a rural versus urban setting or solo practice versus large integrated system. 

Physicians who manage more complex patients (higher level of severity of illness) or who have 

lower SES patient populations often are concerned that they will be disadvantaged under 

performance-based accountability and payment systems. For outcome measures, it is important 

to adjust for differences in the patient mix to level the playing field and to ensure that the 

measures are valid. There is debate about whether to adjust for SES factors related to process 

measures; some practices have been successful in raising performance for minority patients and 

those who are disadvantaged economically when held accountable for these populations. 

Incentive structures can be designed to help mitigate these concerns related to redistribution of 

8 
46 


85440.035

resources away from practices that may need resources to help care for more challenging 

populations and to reduce the likelihood that providers will avoid more challenging populations. 

For example, my RAND team was involved in modeling an incentive design that sorted physician 

practices into "leagues" (based on the education level of patients and capitation rates of 

practices), and held the mean incentive payment equivalent across leagues to avoid large 

redistributions of money, while preserving incentives for improvement (meaning you earned more 

the better you performed within your league). 

(5) Help create an environment where physicians can succeed. 

The goal of incentive programs is to improve care delivery. Medicare can best work to change 

physician culture by helping physicians understand that Medicare is working to do this in 

partnership with physicians, rather than simply imposing change on them. Again, the design of a 

program can set the players up for cooperation to achieve desired goals, which will help promote 

successful implementation. Successful programs work to provide physicians with data and 

reporting to support problem identification and quality improvement, best practices sharing, 

coaching and training, and consultative advice. 

a. Provide on-the-ground quality improvement support. The Centers for Medicare and 

Medicaid (CMS) could support, through cooperative agreements, funding of local community 

collaboratives and organizations that already have established relationships with physicians and 

that have experience helping providers make the changes to drive improvements. An example is 

the California Quality Collaborative, which for the past seven years has been working with 

physicians on practice redesign so they can succeed in improving performance on clinical, 

efficiency, and patient experience measures-all in the context of performance-based payment 

models. Additionally, because private plans are working with the same physicians to drive 

improvements and frequently investing quality improvement resources, CMS could partner with 

private commercial plans in cost-sharing the quality improvement support locally. Many 

commercial plans have the same "stake" in the game because they are financially at risk for 

quality performance in the context of the Medicare Advantage program-and these bonuses are 

substantial in size. The efforts of the public and private payers could align to support physicians in 

improvement. 

b. Continue to support the advancement of clinical decision support (CDS) tools 

embedded within EHRs. To deliver high quality care, physicians need access to information that 

can help them make clinical decisions that are evidence-based and that help them evaluate costeffective alternatives at the point of care. Meaningful use requirements seek to expand the use of 

CDS tools for clinical subspecialties and these tools should be focused on areas where there are 

performance gaps. Development of these tools should help providers be more successful in 

9 
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85440.036

meeting quality requirements. 

c. Allow physicians multiple ways to participate (i.e., submit their data). Various options 

exist for submitting data on individual physician perfonmance, including direct submission by the 

physician (e.g., EHR), submission by the physician's practice or physician group on behalf of the 

physician, or by a physician's specialty society drawing from their registry data. All data, 

regardless of method of submission, should be submitted at the individual physician level, not at 

the practice or group level. Physician-level data are needed to establish benchmarks 

(performance thresholds) and physician level data are required to account for the variation at the 

physician level (note: variation tends to be less at the practice site or group level as it blends the 

results of high and low perfonmers; therefore, using these data would not reflect the entire 

distribution of physician performance). Additionally, should the data be eventually used in the 

context of Physician Compare, the results would need to be physician specific. A number of 

clinical professional societies-such as the American College of Cardiology or the Society for 

Thoracic Surgeons-maintain patient registries that contain important infonmation about the 

quality of care (e.g., appropriateness of procedures, clinical process measures, outcomes). These 

registries are an important potential source of data and may help reduce the burden on 

physicians to comply with program requirements. Several issues that would need to be 

addressed prior to allowing this type of data submission are the need for audit, a data integrity 

assurance process related to the comparability of coding across different providers (e.g., is there 

training of data coders so that they are consistently applying definitions), and permission by the 

specialty society to allow Medicare access and use of the data. 

d. Provide meaningful, timely feedback on performance. To take action to improve, 

physicians will need timely feedback on their performance and how they vary compared to peers. 

Generally, the sponsors of incentive programs are not in the business of providing real-time 

information; instead, that has fallen to the organization within which the physician works because 

the organization is better equipped to provide real time information. Increasingly, in the context of 

ACOs, health plans are partnering with health systems (physicians and hospitals) to provide daily 

reports to alert physicians that a patient's situation is worsening (so at risk for hospitalization) or 

that the patient has been admitted to the hospital or emergency department. Such data are 

valuable to the physician practice so they can intervene quickly to manage the patient in the most 

appropriate setting. Similarly, some integrated health systems are providing real time feedback to 

physicians on their performance (e.g., monthly), flagging areas where performance is lagging or 

signals a problem. While ideally real time data monitoring and feedback would be universal in our 

health system, it is not a near tenm reality. However, as electronic data systems improve and 

CMS is able to leverage data submissions from physicians on a more frequent basis, there is 

10 
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85440.037

potential to develop systems where CMS could generate more timely feedback reports (relative to 

benchmarks}--such as on a quarterly basis. 

e. Foster HIT capabilities to support measure construction. EHRs can be leveraged as a 

data collection and reporting tool. Substantial progress has been made over the past few years in 

working to move EHRs into ambulatory practices. Providers are already receiving technical 

assistance related to EHR implementation through the efforts of the Office of the National 

Coordinator for Health Information Technology (ONC). Within the next five years, the capabilities 

of EHRs will be enhanced and should be designed to support capture of the data elements 

needed to construct performance measures, and CMS working with ONC and EHR vendors need 

to create the appropriate tools to extract needed data and organize it in formats for submission to 

programs such as the SGR incentive program. The ability of physicians in all practice types and 

sizes to collect and report data on performance measures should be enabled by HIT. Already, 

providers across the country are making significant investments in HIT---to enable their 

participation in new care delivery models and payment structures that demand quality outcomes. 

These systems are at the heart of clinical redesign and can provide the front line physician with 

clinical decision support and feedback on performance. CMS should work collaboratively with 

ONC and Electronic Health Record (EHR) vendors to ensure that EHR platforms are able to 

capture required data elements in a structured format to construct performance measures that 

are contained within Medicare measurement, reporting. and incentive programs. Measure 

development moving forward should emphasize e-Measure (meaning constructed from data 

contained in EHRs) development and e-Measures should be tested in a wide array of EHR 

environments prior to being applied nationally to minimize implementation problems. 

6. Period of Transition 

A period of payment stability will allow time to develop and vet measures and build the quality 

infrastructure. The question is how much time is required to start the transition. At noted earlier, 

because measures for primary care already exist and are widely deployed, the Medicare program 

should quickly advance the use of these measures and start all PCPs on the path to data 

collection, reporting, feedback, and improvement. It will likely take the next three years to 

generate a measure portfolio for specialists and to build out other high priority measure areas, 

provided we begin investment today. A potentially faster path for subspecialists is leveraging data 

already captured by specialty societies in registries that could allow the transition to begin sooner 

for the subset of clinical subspecialists that are reporting data to registries. 

Earlier in my testimony I had commented on the perverse incentives in FFS payment structures 

11 
49 


85440.038

to provide more services irrespective of quality or costs. While the focus of my comments has 

been on embedding performance-based incentives into the existing FFS payment model, I 

would underscore for the Committee that more wholesale payment reform is required to move 

us beyond a payment structure that incentivizes physicians to do more, often with little to no 

clinical benefit or that may even harm the patient. The incentive structures I've discussed today 

work at the margin rather than on the structure of the base payment. To that end, I would 

encourage Congress to enable CMS and local communities to conduct payment reform 

innovations across the United States, allowing payers, physicians, and other stakeholders in 

communities to innovate to advance the delivery of high value health care. 

Conclusion 

In summary, design does matter related to whether and how providers will respond and how 

successful the incentive program will be. The ability to move successfully fOlWard with new 

performance-based payment models is predicated on having (1) a robust set of measures; (2) a 

good incentive design; and (3) a support structure that can help physicians participate and 

succeed in the program. 

As Congress considers the design of an incentive program, there are several areas where 

federal leadership and investment can facilitate and support the transition to performance based 

payment. 

For clinical subspecialists, 

1. Provide federal investment in the development of measures, to address the care 

delivered by subspecialists and to fill important performance measure gap areas (such as 

efficiency/overuse of services, care coordination, and outcomes): 

o Use a rigorous, transparent and inclusive process to develop measures. 

Because performance measurement will affect the behavior of physicians and 

the organizations in which they work, it is important that what we ask them to 

focus on is based on scientific evidence related to actions they can take to 

influence the outcomes of interest. While CMS may fund or lead efforts to 

develop measures working with measure development experts, physicians 

should be actively involved in these efforts, could lead such efforts. Existing 

physician-led data registries that track processes and outcomes could be 

leveraged. 

12 
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85440.039

o Ensure measures are valid and reliable. The development process should 

ensure that the measures that will be applied in high stakes applications are valid 

and reliable. Results from testing of measures should be publicly available for 

physicians to review; such transparency will build confidence in the measurement 

system, 

o Ensure that measures reflect the current evidence base: eMS should 

provide resources to update measures (or retire them) to incorporate changes in 

the scientific evidence, 

2. Begin the transition now for Primary Care. eMS can leverage the ambulatory care 

measures (most of which address primary care) drawn from Medicare Advantage and private 

payer performance measurement programs. These are well-vetted measures that are in routine 

use nationally. 

3. Structure the incentive to achieve the desired result. 

o Pay along the continuum: The incentive structure should provide incentive 

rewards along the continuum of performance (with some minimum threshold 

that must be met to get any incentive) so that providers are rewarded for each 

increment of improvement. Incentivize improvement more at the low and middle 

of the continuum more than at the top, as the lower performers are making 

critical investments to succeed. 

o Use fixed thresholds 

o Make payments meaningful 

4, Create an environment where providers can succeed: eMS can create a culture of 

working in partnership to achieve the desired goals by supporting providers in their efforts to 

improve. Recommended actions include: 

o Work to build support structures with local community partners who can help 

physicians with quality improvement support and system redesign. 

o Facilitate sharing of best practices and learning networks among peer 

subspecialties 

13 
51 


85440.040

o Provide meaningful, timely feedback on performance. 

o Continue to support the advancement of clinical decision support to help 

providers meet quality requirements. Work with EHR vendors to ensure that 

EHR are able to capture in structured data fields (rather than free text) the data 

required to construct performance measures. 

o Allow providers flexibility in how they can participate and submit data 

RAND researchers have developed performance measures, (McGlynn et aI., 1995; Wenger et al., 

2003), evaluated the impact of pay-for-performance (Damberg et aI., 2009), and more recently 

value-based purchasing programs, helped to define alternative measurement approaches that 

can support new payment models (Hussey et aI., 2009), and assessed the implications of 

alternative incentive designs and scoring systems to reward performance (Schneider et aI., 2012; 

Mehrotra et ai., 2010; Damberg et aI., 2009; Stecher et aI., 2010; Friedberg and Damberg, 2012). 

We are happy to work with Committee members to share the work we have done in this area to 

inform policy making. 

Again, let me thank you Mr. Chairman, Mr. Ranking Member, and members of the Subcommittee 

for allowing me to appear before you today to discuss this important issue. I would be happy to 

take your questions. 

14 
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85440.041

References 

Damberg, Cheryl L., Kristiana Raube, Stephanie S. Teleki, and Erin dela Cruz, "Taking Stock Of 

Pay-For-Perfonnance: A Candid Assessment From The Front Lines," Health Affairs, Vol. 28, No.2, 

2009, pp. 517-525. 

Damberg, Cheryl L., Justin W. Timbie, Douglas S. Bell, Liisa Hiatt, Amber Smith, Eric C. Schneider, 

Developing a Framework for Establishing Clinical Decision Support Meaningful Use Objectives for 

Clinical Specialties, Santa Monica, California: RAND Corporation, TR-1129, 2012. 

Damberg, Cheryl L. and Marc E. Elliott, "Moderating Unintended Effects on Providers Serving 

Disparate Patient Populations: Post-Adjustment of Value-Based Incentive Payments Based on 

Leagues: Academy Health 2012 Annual Meeting, Orlando: June 25, 2012. 

Darnberg, Cheryl L., Melany E. Sorbero, Susan L. Lovejoy, Katharine Lauderdale, Sarnuel 

Wertheirner, Amber Smith, Daniel Waxman, and Christopher Schnyer, An Evaluation of the Use of 

Performance Measures in Health Care, Santa Monica, California: RAND Corporation, TR-1148, 

2011. 

Hussey, Peter S., Melany E. Sorbero, Ateev Mehrotra, Hangsheng Liu, and Cheryl L. Damberg, 

"Episode-Based Performance Measurement and Payment: Making it a Reality," Health Affairs 

(Millwood), Vol. 28, No.5, 2009, pp. 1406-1417. 

McGlynn, Elizabeth A., Cheryl L. Damberg, Eve A. Kerr, and Mark A. Schuster (eds.). Quality of 

Care for Children and Adolescents: A Review of Selected Clinical Conditions and Quality Indicators, 

Santa Monica, California: RAND Corporation, MR-1283-HCFA,1995. 

McGlynn, Elizabeth A., Eve A. Kerr, Cheryl L. Damberg, and Steven M. Asch (eds.). Quality of Care 

for Women: A Review of Selected Clinical Conditions and Quality Indicators, Santa Monica, 

California: RAND Corporation, MR-1283-HCFA, 1995. 

Mehrotra, Ateev, Melany E. Sorbero, and Cheryl L. Damberg, "Using the Lessons of Behavioral 

Econornics to Design More Effective Pay-for-Perforrnance Programs: American Joumalof 

Managed Care, Vol. 16, No.7, 2010, pp. 497-503. 

National Quality Measures Clearinghouse (NQMC), Tutorials on Quality Measures, as of February 

11, 2013: http://www.qualityrneasures.ahrq.gov/tutorial/index.aspx. 

15 
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85440.042

National Quality Strategy, National Quality Strategy will Promote Better Health, Quality Care for 

American, As of February 11, 2013, http://www.hhs.gov/news/press/2011pres/03/20110321a.html. 

Schneider, Eric C., Peter S. Hussey, and Christopher Schnyer, Payment Refonn: Analysis of 

Models and Perfonnance Measurement Implications, Santa Monica, California: RAND Corporation, 

TR841 , 2011. 

Stecher, Brian M., Frank Camm, Cheryl l. Damberg, laura S. Hamilton, Kathleen J. Mullen, 

Christopher Nelson, Paul Sorensen, Martin Wachs, Allison Yoh, Gail l. Zellman, and Kristin J. 

leuschner, Toward a Culture of Consequences: Performance-Based Accountability Systems for 

Public Services, Santa Monica, California: RAND Corporation, MG1019, 2010. 

Wenger Neil S., David H. Solomon, Carol P. Roth, Catherine H. Maclean, Debra Saliba, Caren J. 

Kamberg, laurence Z. Rubenstein, Roy T. Young, Elizabeth M. Sloss, Rachel louie, John Adams, 

John T. Chang, Patricia J. Venus, John F. Schnelle, and Paul G. Shekeile, "The Quality of Medical 

Care Provided to Vulnerable Older Patients," Annals of Internal Medicine, Vol. 139, No.9, 2003, pp. 

740-7. 

16 
54 

Mr. PITTS. And now recognize Mr. Kramer for 5 minutes for an 

opening statement. 

STATEMENT OF WILLIAM KRAMER 

Mr. KRAMER. Thank you, and good morning. My name is Bill 

Kramer from the Pacific Business Group on Health. I would like 

to express our deep appreciation to Chairman Joe Pitts, Vice Chairman Dr. Michael Burgess, as well as to Ms. Donna Christensen on 

behalf of Ranking Member Minority Member Frank Pallone, for 

convening today’s hearing. I want to applaud the committee for 

stepping up to the challenge of finding a solution to this very important issue. 

PBGH represents large employers who want to improve the quality and affordability of health care. PBGH consists of 60 member 

companies with employees in all 50 States that provide healthcare 

coverage of up to 10 million Americans and their dependents. Our 

members include many large national employers, such as GE, 

Walmart, Boeing, Tesla, Disney, Intel, Chevron, Wells Fargo, and 

Safeway, as well as public sector employers. 

The basis for my testimony today is our members’ significant experience in designing and implementing innovations in provider 

payment and care delivery. We believe the lessons learned in private sector purchasing can be applied to Medicare. 

There are three key points I want to make in today’s testimony. 

First, businesses have a big stake in how Medicare works. Second, 

large employers want to see physician payment tied directly to the 

value of the services that are provided. And third, we need new 

and better performance measures to support a new physician payment system. 

First, why should businesses care about how Medicare works? 

For decades, large employers have been frustrated by the rising 

cost and inconsistent quality of health care. They know we need to 

change the way we pay providers. Large employers have supported 

innovative approaches to physician payment, such as the intensive 

outpatient care program piloted by Boeing and adopted by many 

other large employers. 

We know, however, that these innovations do not have the scale 

to drive system-wide change and improve health care across the 

Nation. We need America’s largest healthcare purchaser, the Federal Government, to work in alignment with us and join our efforts 

and apply its purchasing strategies as purposefully as our businesses do. 

Second, large employers want to see physician payment tied directly to the value of services that are provided. We need to replace 

Medicare’s current fee-for-service system over time with payment 

based on performance with a goal of achieving measurable improvements in quality and affordability. The new physician payment system should encourage individual as well as group accountability. 

Although team-based care is often very effective, in many situations patients are most concerned about the performance of individual physicians. I recently had surgery to repair a broken bone 

in my face, an injury resulting from an elbow to the eye during a 

pickup basketball game. While I was pleased to know that I would 

55 

receive care within a large, high-quality healthcare system, what 

I really wanted to know was the track record of that surgeon. What 

was his success rate? How many infections or surgical complications did the patient have. By far the most important thing to me 

was that surgeon’s performance record. 

Third, we need to develop more and better performance measures. Among the nearly 700 measures endorsed by the National 

Quality Forum, the large majority are clinical process or structural 

measures. While these can be valuable for quality improvement initiatives by physicians, they do not provide information about the 

things that patients and employers care most about. We strongly 

recommend that Congress provide support for the rapid development and use of better performance measures, including patient-reported outcomes, patient experience of care, care coordination, appropriateness of care, and total resource use. The selection of these 

measures should be based on input from physicians, but ultimately 

be determined by those who receive and pay for care. 

In summary, first, businesses have a big stake in how Medicare 

works and Medicare should adopt successful purchasing practices 

from the private sector. Second, large employers want to see physician payment directly tied to the value of services that are provided. PBGH and its member companies strongly support the replacement of the SGR as long as the new payment system results 

in significant improvements in healthcare quality and affordability. 

Third, Congress should invest in the development of new and 

better performance measures to undergird the new payment system. The selection of these measures must meet the needs of those 

who receive and pay for care—patients, employers, and taxpayers. 

Our Nation desperately needs to improve its healthcare system, 

and the SGR replacement is a rare opportunity to give it a shot in 

the arm. PBGH applauds the committee’s efforts to get it right, and 

we offer our real world experience and expertise to you in advancing this important initiative. Thank you, and I am happy to answer 

any questions from the committee members. 

Mr. PITTS. Thank you. 

[The statement of Mr. Kramer follows:] 

56 


85440.043

Statement for the Record 

Pacific Business Group on Health 

2'::1 \1 \1, :-.T1\1-I -I,;;\. ITI 

:-\, I'R \"( j:'( I\!. \ 

Hearing before the House Committee on Energy and Commerce 

Subcommittee on Health 

"Reforming SGR: Prioritizing Quality in a Modernized Physician Payment System" 

June 5, 2013 

1 
57 


85440.044

House Energy & Commerce - Health Subcommittee Hearing 

June 5, 2013 

Testimony 

Good morning. My name is Bill Kramer, and I serve as Executive Director for National Health Policy 

at the Pacific Business Group on Health. On behalf of PBGH, I would like to express our deep 

appreciation to Chairman Joe Pitts, Vice Chairman Dr. Michael Burgess, and Ranking Minority 

Member Frank Pallone for convening today's hearing on physician payment policy under 

Medicare. I want to applaud the Committee for stepping up to the challenge of finding a solution on 

this very important issue. 

The Pacific Business Group on Health represents large employers who want to improve the quality 

of health care and moderate cost increases. PBGH consists of 60 member companies, with 

employees in all 50 states, that provide health care coverage to 10 million Americans and their 

dependents. Our members include many large national employers such as GE, Walmart, Boeing, 

Tesla, Target, Disney, Intel, Bechtel, Chevron, Wells Fargo and Safeway, as well as public sector 

employers such as CalPERS and the City and County of San Francisco.; The basis for my testimony 

today is our members' significant experience in designing and implementing innovations in provider 

payment and care delivery. We believe the lessons learned in private sector purchasing can be 

applied to Medicare. 

There are three key pOints that I want to make in today's testimony: 

1. Businesses have a big stake in how Medicare works. 

2 
58 


85440.045

'::1 \l\I'\.~mU"l:-'l 

~ \'\. j R \'\.r 1:-,( (\ I 

2. Large employers want to see physician payment directly tied to the value of the services 

that are provided. 

3. We need new and better performance measures to support a new physician payment 

system. 

First, why should businesses care about how Medicare works? 

For decades, large employers have been frustrated by the rising costs and inconsistent quality of 

health care, and they know we need to change the way we pay providers. Large employers have 

supported innovative approaches to physician payment, such as the Intensive Outpatient Care 

Program piloted by Boeingii and adopted by other large employers;;;. Another example is the Hill 

Physicians Medical Group in California, in which a significant portion of physician payment is based 

on value, not just the volume of services." Large employers know, however, that these innovations 

do not have the scale to drive system-wide change and improve health care across the nation. We 

need America's largest health care purchaser, the federal government, to join our efforts and apply 

its purchasing strategies as purposefully as our businesses do. 

Second, large employers want to see physician payment directly tied to the value of the services 

that are provided -- clinical quality, patient-reported outcomes, and total cost of care. We need to 

replace Medicare's current fee-for-service system with payment based on performance, with the 

goal of achieving measureable improvements in quality and affordability. 

3 
59 


85440.046

\1 \j, :<:Hi rll 

;.-\,lR\'U'( 

The new physician payment system should encourage individual as well as group 

accountability. Although team-based care is often very effective, patients are most concerned 

about the performance of individual physicians. I recently had surgery to repair a broken bone in 

my face - an injury resulting from an elbow to the eye during a pick-up basketball game. While I 

was pleased to know that I would receive care within a large, high quality health care system, what I 

really wanted to know was the track record of the surgeon. What was his success rate? How many 

infections or post-surgical complications did his patients have? By far the most important thing to 

me was that surgeon's performance record. 

Third, we need to develop more and better performance measures. Among the nearly 700 

measures endorsed to-date by the National Quality Forum, the large majority are clinical process or 

structural measures." While these can be valuable for quality improvement initiatives by physicians, 

they do not provide information about the things that patients and employers care about most. We 

strongly recommend that Congress provide support for the rapid development and use of better 

performance measures, including patient-reported outcomes, patient experience of care, care 

coordination, appropriateness of care, and total resource use. The selection of these measures 

should be based on input from physicians but ultimately be determined by those who receive and 

pay for care. 

In summary, 

1. Businesses have a big stake in how Medicare works, and Medicare should adopt successful 

purchasing practices from the private sector. 

4 
60 


85440.047

\1 \1"- ~ ['1\1 j·.l :': 1"11 

S\"- i'R.\"-U:.--( (l,i_ \ LI..jI1'~ 

2. Large employers want to see physician payment directly tied to the value of the services 

that are provided -- clinical quality, patient-reported outcomes, and total cost of care. PBGH 

and its member companies strongly support the replacement of the SGR, but only if the new 

payment system results in significant improvements in health care quality and affordability. 

3. Congress should invest in the development of new and better performance measures to 

undergird the new payment system. The selection of these measures must meet the needs 

of those who receive and pay for health care - patients, employers and taxpayers. 

In other words - Put patients first. help them identify the best doctors, and reward those doctors, 

Our nation desperately needs to improve its health care system, and the SGR replacement is a rare 

opportunity to give it a shot in the arm, The Pacific Business Group on Health applauds the 

Committee's efforts to get it right, and we offer our real-world experience and expertise to you in 

advancing this important initiative. 

'Full list of PBGH members can be found at http:!(www.pbgh.org(about!members. 

;; Milstein, A and Kothari P, Health Affairs, October 20,2009. Accessed at 

http://healthaffairs.org!blog(2009(10(20/are-higher-value-care-models-replicable/. 

iii Additional information about the IOCP program can be found at http://www.pbgh.orgiiocp. 

5 
61 


85440.048

\1 \1"- ~1l:LI i . ....: JT! 

:-- \"- 1'](, \".( hi (l, 1 \ q41'1~ 

i" T, Emswiler and L. Nichols, Hill Physicians Medica! Group: Independent Physicians Working to Improve 

Quality and Reduce Costs, The Commonwealth Fund, March 2009. 

http://www,commonwealthfund.org/ ..... !medfa/Files/Publfcations/Case%20StudyI2009!March/HiH%20Physicia 

ns%20Medical%20Group/1247 Emswiler Hill case study rev.pdf 

""Developing a Viable Physician Payment Policy". Statement of: Frank G. Opelka, MD, FACS, National Quality 

Forum. House Ways & Means Committee, Health Subcommittee hearing, May 7, 2013, 

http://waysandmeans,house.gov/calendar/eventsingle.a 5 px? Eventl D=332173. 

6 
62 


85440.049

Supplemental Materials 

Pacific Business Group on Health 

Hearing before the House Committee on Energy and Commerce 

Subcommittee on Health 

"Reforming SGR: Prioritizing Quality in a Modernized Physician Payment System" 

June 5, 2013 
63 


85440.050

PBGH 

House Energy & Commerce Subcommittee on Health 

Reforming SGR: Supplemental Materials 

June 5, 2013 

Summary afkev testimanv messages: 

1. Businesses have a big stake in how Medicare works, and Medicare should adopt successful 

purchasing practices from the private sector. 

2. Large employers want to see physician payment directly tied to the value of the services 

that are provided -- clinical quality, patient-reported outcomes, and total cost of care. PBGH 

and its member companies strongly support the replacement of the SGR, but only if the new 

payment system results in significant improvements in health care quality and affordability. 

3. Congress should invest in the development of new and better performance measures to 

undergird the new payment system. The selection of these measures must meet the needs 

of those who receive and pay for health care - patients, employers and taxpayers. 

Supp/ementa//nfarmatian far Key Message #1 

Large employers have supported innovative approaches to physician payment, such as the Intensive 

Outpatient Care Program (lOCP) piloted by Boeing and adopted by other large employersi

. The IOCP 

is a primary care-led, high intensity care management model for high risk populations. The 

California HealthCare Foundation (CHCF) provided the funding to develop this groundbreaking 

model of delivering care as a strategy for reducing costs while maintaining or improving quality. The 

designs and financial projections underwent a peer review panel of subject matter experts and 

leaders of traditional and more innovative practices. Key features of the model include: 

• A focus on high risk patients, i.e., the 5-20% who incur the highest costs. 

• Each site creating a new ambulatory intensivist practice. 

• Shared care plans, increased access, and proactively managed care. 

• Copays for the initial intake visit were waived; there were no other benefit changes. 

• Sites were paid a case rate per member per month (pmpm) to cover non-traditional 

services; otherwise, the sites continued to be paid based on traditional fee-for-service 

contracts. 
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• The sites received a portion of the savings in total medical expenses. 

The Boeing Company initially implemented a pilot of this model in Seattle. Over a two-year period, 

Boeing achieved improved health outcomes (28% reduction in hospital admissions, 16% increase in 

mental functioning on the SF-36), 20% reduction in costs, and increased patient access to care.ii,w 

Following the success of the Boeing pilot, PBGH worked with CalPERS and Pacific Gas & Electric 

Company (PG&E) to replicate the model in rural Northern California with the Humboldt del Norte 

Foundation Medical Group. This program targets the top 20 percent of patients in terms of relative 

health risk. PBGH is now expanding the IOCP to the Medicare population. Under a grant from the 

CMMI, PBGH is rolling out this model to 17 medical groups in California, covering 23,000 Medicare 

patients, demonstrating commitment to public and private sector alignment.;' 

Other PBGH members are experimenting with models for accountable care organizations (ACO). For 

instance, CalPERS implemented an ACO-like pilot with Hill Physicians Medical Group, Dignity Health 

and Blue Shield of California that introduced a shared savings model for improving care coordination 

and quality for 42,000 HMO beneficiaries in the greater Sacramento area, Early results showed a 

$15.5 million cost reduction annually due to a 17% reduction in patient readmissions and shorter 

lengths of stay: Five months later, those results were updated to reflect $20 million cost reduction 

over the two years of the program, largely due to a 22% reduction in hospital readmissions,';' vii 

Large employers know, however, that these innovations do not have the scale to drive system-wide 

change and improve health care across the nation. As the largest health care purchaser, it is 

important to have the collaboration of the federal government in transforming the way health care 
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is delivered. Working together is also important to large employers to avoid the shifting of costs 

from the public to the private sector. In some markets, cost-shifting from Medicare to private 

payers can be as high as 40%.,in.i.,, Instead we should pursue strategies to improve quality while 

lowering the overall cost of care. 

Supplemental Information for Kev Message #2 

The new physician payment system should encourage individual as well as group 

accountability. Individual physician accountability reinforces professional motivation for quality 

improvement, identifies variation that is masked by higher levels of aggregation,i .• ii and is more 

appropriate in some instances. Although team-based care is often very effective, patients are most 

concerned about the performance of individual physicians. 

Shared accountability also has a role in driving improvements in health care. It supports team-based 

care, coordination across providers, and progress toward a genuine system of care. Shared 

accountability can be accomplished by reporting at an aggregate level, such as the practice site, or 

basing physician-specific results on both physician and team (e.g., medical group) performance. 

The new payment system should also reward high performers at a level that drives behavior. Over 

time as the program becomes more sophisticated, it should make a significant contribution to total 

compensation. For example, Hill Physicians Medical Group in California physician compensation is 

comprised of over 15% value-based compensation, and in some instances at high as 30_40%.'iii Hill 

Physicians are consistently rated in the top tier of performance in California's IHA Pay-forPerformance program. In 2010, Hill Physicians distributed $38.6 million from IHA and their internal 
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value-based payment program."Y Hill Physicians Medical Group is an Independent Practice 

Association in Northern California, established in 1984, with over 3,800 physicians that serves 

300,000 consumers." 

Supp/ementa//nfarmatian far Key Message #3 

Many parties have a stake in the development and use of better measures for physician payment. 

PBGH has worked collaboratively with providers, payers, consumers and other stakeholders to 

support efforts to improve health care quality and outcomes while at the same time getting better 

value for the health care dollar. We engage in, and sometimes lead, multi-stakeholder collaborative 

processes to develop, evaluate, endorse, and recommend performance measures for use in federal 

and California-based reporting and payment programs. Physician involvement is critical in this 

process, but the ultimate stakeholders are those who receive and pay for medical care. It is 

essential for the process to involve all stakeholders, including strong representation from consumers 

and purchasers. 

Ultimately, though, the HHS Secretary will decide which measures are used in Federal physician 

payment programs. That said, multi-stakeholder input to HHS via pre-rulemaking of the Measure 

Applications Partnership is a key part ofthe consensus-based entity National Quality Forum 

measure review and endorsement process and both should continue to be supported. 
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An example of multi-stakeholder collaborative using measures that meet the needs of a variety of 

users is the California Joint Replacement Registry (CJRR). Joint replacements have become the 

highest volume-and highest cost-surgeries for both Medicare and private payers. From 2001 to 

2009, the rate of primary hip replacements increased by 52%, while the rate of primary knee 

replacements almost doubled.'v; Working with the California Orthopedic Association and the 

California HealthCare Foundation, PBGH launched the CJRR, a Level 3 clinical registry. The registry 

is: (1) collecting and reporting scientifically valid data on the results of hip and knee replacements 

performed in California, including device safety and effectiveness, post-operative complication and 

revision rates, and patient-reported assessments; and (2) encouraging quality and cost 

improvements through marketplace mechanisms by using performance information to guide 

physician and patient decisions and supporting programs for provider recognition and reward. 

There are 12 sites, which include 61 surgeons, submitting data and represent 20% of the California 

hip and knee replacement cases each year. An additional 19 sites are in the process of joining the 

program,XVii 

, Additional information about the IOCP program can be found at http://www.pbgh.org/iocp. 

;; Milstein, A and Kothari P, Health Affairs, October 20, 2009. Accessed at 

http://healthaffairs.org/blog/2009/10/20/are-higher-value-care-models-replicable/ 

;;; This model was also highlighted in Atul Gawande's "Hot Spotters" article in the New Yorker, and documented on the 

Agency for Healthcare Research and Quality (AHRQ) Health Care Innovations Exchange. 

http:Uwww.innovations.ahrg.gov!content.aspx?id=2941. Additionally, Steve Jacobson, MD and Jennifer Wilson-Norton of 

The Everett Clinic presented on "Connecting Providers and Managing High Risk Beneficiaries" at the CMS ACO Accelerated 

Development Learning Session on September 16, 2011, https:l!acoregister.rtLorg!docx!dsp Inks.cfm?doc=Module 3B. 

Connecting Providers Managing High Risk.pdf. 

;, http://www.pbgh.org!key-strategies!paying-for-value!28-aicu-personalized-care-for-complex-patients. 
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, CalPERS Press Release, (2011, April 12). Press Release: Aprill2, 2011. Retrieved February 21, 2012, from 

www.calpers.ca.gov: http://www.calpers ca .gov/index. jsp ?bc=/a bout!presllir -20 l1/april/integrated-health.xm I. 

,i CalPERS Agenda Item 4. (2011, October 18). Agenda Item 4 Memo to the Members of the Health Benefits Committee. 

Retrieved February 21, 2012, from www.calpers.ca.gov: http://www.calpers.ca.gov/eip-docs/about/board-calagenda!agendas!hbc!201110/item-4.pdf. 

wi Blue Shield of California Press Release. (2011, September 16). HHS Secretary Kathleen Sebelius Reviews Key Pilot 

Progrom Tied to Health Care Reform Goals. Retrieved June 3, 2013, from www.blueshieldca.com: 

https:llwww.blueshie!dca.com/bsca/aboutMb!ue~shield/newsroom/sebelius-reviews-aco-pilot-programs.so . 

• ii W Fox & J Pickering. Cost Efficiency at Hospital Facilities in California: A Report Based on Publicly Available Data. 

Millman. Oct 2007. 

i, Analysis of Hospital Cost Shift in Arizona. The Lewin Group. March 2009. 

Jt Health Care Trends in America. BlueCross BlueShield Association. 2009 Edition. 

XI H.P Rodriguez et aL Attributing Sources of Variation in Patients' Experiences of Ambulatory Care. Medical Core 2009; 47: 

83S-841. 

XII Massachusetts Health Quality Partners, Quality Insights: Patient Experiences in Primary Care, 

http://www.mhqp.org/quality/pes/pesTechApp.asp?nav=031638&view=print. 

xiii T. ErnsWlier and L Nichols, Hil! PhYSicians Medic.a! Group: Independent Physklam Working to Improve Quality and 

Reduce Costs! The Commonwealth Fund, M<lfCh 2009. 

http://www.commonwealthfund.org(~/media/Files/Publications/Case%20Study/2009/March/Hill%20Physicians%20Medlc 

al%20Group/1247 Emswiler Hill case study rev.pdf. 

XIV http://www.hiUohysicians.com!ourdoctors!Providerlnfo!Pages!Pay-for-Performance.aspx. 

~ http://www.hillphysicians.com/AboutUs/Pages/fact-sheet.aspx 

XV! The Agency for Healthcare Research and Quality. National and regional estimates on hospital use for all patients from 

The HCUP Nationwide Inpatient Sample (NIS). http://hcupnet.ahrq.gov/. Accessed June 3, 2013. 

"" http://caljrr.org!about!CJRR-2013-progress-update.aspx. 
69 

Mr. PITTS. The chair thanks the gentleman, and now recognizes 

Dr. Rich 5 minutes for an opening statement. 

STATEMENT OF JEFFREY B. RICH 

Dr. RICH. Thank you, and good morning. Chairman Pitts, Representative Christensen, and distinguished members of the committee. Thank you for the opportunity to present my testimony 

today on the behalf of the Society of Thoracic Surgeons. 

I come to you wearing many hats. As mentioned, I am the immediate past president of the Society of Thoracic Surgeons and an active participant in our national database, one of the longest running, most robust clinical outcome data registries in existence. 

More importantly, or as importantly, I am the former director for 

the Center for Medicare Management at CMS. In other words, I 

ran the Medicare fee-for-service system in the last years of the 

prior administration and was involved very much in value-based 

purchasing and also physician reform initiatives. 

I am a founder and director of the Virginia Cardiac Surgery 

Quality Initiative. I am now a practicing cardiac surgeon at 

Sentara Heart Hospital and president of the Mid-Atlantic 

Cardiothoracic Surgeons, so I have an active clinical practice and 

understanding of payment and payment reform. 

The Society of Thoracic Surgeons represents more than 6,000 

surgeons, researchers, and allied healthcare professionals who are 

dedicated to providing patient-centered high-quality care to patients with chest and cardiovascular diseases, including heart, 

lung, esophagus, transplantation, and critical care. The STS National Database was established in 1989 as an initiative for quality 

assessment, improvement in patient safety among cardiothoracic 

surgeons. The fundamental principle underlying the STS database 

initiative has been that engagement in the process of collecting information on every case, robust risk adjustment based on pooled 

national data, and feedback of this risk-adjusted data to the individual practice and institution will provide the most powerful 

mechanism to change and improve the practice of cardiothoracic 

surgery for the benefit of patients and the public. And I might add 

that the database will serve as a platform in all phases of reform, 

I, II, and III. 

The Virginia Cardiac Surgery Quality Initiative was founded in 

1994 by myself and others with the expressed purpose of improving 

clinical quality across an entire State in cardiac surgical programs 

of all sizes through data sharing, outcomes analysis, and process 

improvements. All of the Virginia programs participate in the STS 

National Database and uniformly follow the definitions and measures in its landmark clinical registry. 

The database in our State has been unique in that it matches the 

patient clinical outcome data with each patient’s discharge financial data from CMS on an ongoing basis. Each record includes clinical outcomes tied to the cost of each episode of care. In Virginia 

we have demonstrated that improving quality reduces costs. For 

example, using evidence-based guidelines, the Virginia Cardiac 

Surgery Quality Initiative has generated more than $43 million in 

savings over the last 2 years by reducing blood transfusions in the 

State. In addition we have reduced atrial fibrillation, a common 

70 

heart arrhythmia after surgery, and saved another 20-plus million 

dollars over the last 5 to 7 years. So it has been an effective tool 

for us not only to improve quality, but to provide cost savings 

throughout the States. 

Since survival and resource utilization information is such an important part of the outcomes for cardiothoracic surgery quality improvement efforts, we urge that steps be taken to ensure these registries have access to administrative or financial data from CMS, 

and hopefully other payers, both for episodes of care and longitudinal follow-up, as well as outcomes data from the Social Security 

Administration or another accessible source. It is imperative that 

SGR reform legislation addresses this foundational issue and gives 

us a clinical financial tool to create improvement. 

STS wishes to commend the committee and your colleagues on 

the Ways and Means Committee for taking the first steps toward 

meaningful physician payment reform. STS has provided substantial comments on the concept document released by the committees 

on April 3rd that we submit here for the record. Today I would like 

to highlight a few of our conceptual comments for the committee 

related to that proposal in a discussion draft just released last 

week. 

STS is particularly grateful to this committee for your recognition of the utility of clinical registries in pursuit of a pay-for-quality 

physician payment system. To that end, we recognize that Congress faces a challenge in that many specialties do not yet have the 

ability to collect clinical data, develop risk-adjustive quality measures, and implement physician feedback and quality improvement 

programs. 

That said, we hope that implementation of a pay-for-quality program will not have to wait for all of medicine to be at the same 

place at the same time. We believe that early innovators who are 

able to enter into Phase II, or even Phase III, should be able to do 

so now, while others are trying to play a game of catchup, if you 

would. For that reason, we recommend that policymakers consider 

ways to reward providers for incremental steps towards these quality assessment and improvement goals, while allowing those medical professionals whose specialties that already have the requisite 

infrastructure in place to engage in this new system as soon as possible. 

We do believe that it is important to use the STS database for 

other uses—medical liability reform, public reporting. We believe 

that empowerment of patients with data is important and advancing medical technology. 

In conclusion, we wish to thank you for your time and understanding and listening to our plea for engaging with the rest of 

medicine in clinical data and outcomes assessment. 

Mr. PITTS. The chair thanks the gentleman. 

[The prepared statement of Dr. Rich follows:] 

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Thoracic Surgeons 

STS Headquarters 

633/11 Saint Clair St. ~l()()r 23 

STS Washington Office 

20FStNW,Ste310C 

Washington,Df20001-6704 

(202)787-1230 

advo(a.:y@sts.org 

www.sts.org 

House Committee on Energy and Commerce 

Subcommittee on Health 

Hearing: Reforming SGR: Prioritizing Quality in a Modernized Physician 

Payment System 

June 5, 2013 

Jeffrey B. Rich, MD, Testimony on behalf of 

The Society of Thoracic Surgeons 

I Chairman Pitts, Ranking Member Pallone, and distinguished members of the 

Committee, thank you for the opportunity to present my testimony today on 

behalf of The Society of Thoracic Surgeons. I come to you wearing many 

hats: Immediate Past President of The Society of Thoracic Surgeons and 

participant in the STS National Database - one of the longest running, most 

robust clinical outcomes data registries in existence; former Director of the 

Center for Medicare Management at the Centers for Medicare and Medicaid 

Services (CMS); Director at Large of the Virginia Cardiac Surgery Quality 

Initiative; and a practicing cardiothoracic surgeon at Sentara Heart Hospital 

and President of Mid-Atlantic Cardiothoracic Surgeons, Ltd. in Norfolk, VA. 

The Society of Thoracic Surgeons (STS) is the largest organization 

representing cardiothoracic surgeons in the United States and the world. 

Founded in 1964, STS is an international, not-for-profit organization 

representing more than 6,600 surgeons, researchers, and allied health care 

professionals in 85 countries who are dedicated to providing patient-centered 

high quality care to patients with chest and cardiovascular diseases, including 
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heart, lung, esophagus, transplantation, and critical care. The mission of the Society is to enhance 

the ability of cardiothoracic surgeons to provide the highest quality patient care through 

education, research, and advocacy. 

The STS National Database was established in 1989 as an initiative for quality assessment, 

improvement, and patient safety among cardiothoracic surgeons. The STS National Database has 

three components-Adult Cardiac, General Thoracic, and Congenital Heart Surgery. The 

fundamental principle underlying the STS database initiative has been that engagement in the 

process of collecting information on every case, robust risk-adjustment based on pooled national 

data, and feedback of this risk-adjusted data to the individual practice and institution will provide 

the most powerful mechanism to change and improve the practice of cardiothoracic surgery for 

the benefit of patients and the public. In fact, published studies indicate that the quality of care 

has already improved as a result of research and feedback from the STS National Database. 

For example, ElBardissi and colleagues studied 1,497,254 patients who underwent isolated 

primary Coronary Artery Bypass Graft (CABG) surgery at STS National Database-participating 

institutions from 2000 to 2009. They found that: 

• Patients received more indicated care processes in recent years, including a 7.8% 

increase in the use of angiotension-converting enzyme inhibitors preoperatively and a 

significant increase in the use of the internal thoracic artery (88% in 2000 vs. 95% in 

2009). 
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• The observed mortality rate over this period declined from 2.4% in 2000 to 1.9% in 

2009, representing a relative risk reduction of24.4% despite the predicted mortality 

rates (2.3%) remaining consistent between 2000 and 2009. 

• The incidence of postoperative stroke decreased significantly from 1.6% to 1.2%, 

representing a relative risk reduction of26.4%. 

• There was also a 9.2% relative reduction in the risk of reo per at ion for bleeding and a 

32.9% relative risk reduction in the incidence of sternal wound infection. 

The Virginia Cardiac Surgery Quality Initiative (VCSQI) was formed in 1994, with the express 

purpose of improving clinical quality across an entire state in cardiac surgical programs of all 

sizes through data sharing, outcomes analysis, and process improvements. It is founded on the 

principle that a focus on quality will contain costs by lowering complications, improving 

efficiency, and reducing resource utilization. All of the VCSQI programs participate in the STS 

National Database and uniformly follow the definitions and measures in this landmark clinical 

registry. This regional quality initiative has constructed a database of over 80,000 patients who 

have undergone cardiac surgical procedures. The database is unique in that it matches the 

patient's clinical outcome data with each patient's discharge financial data on an ongoing basis. 

Each record includes clinical outcomes tied to costs for each episode of care. VCSQI has served 

as a test bed for the STS's evidence-based guidelines to be implemented. 

VCSQI has attempted to test a global pricing model and has implemented a pay-for-performance 

program whereby physicians and hospitals are aligned with common objectives. Although this 

collaborative approach is a work in progress, collaborators point out that a road map of short-
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term next steps is needed to create an adaptive payment system tied to the national agenda for 

reforming the delivery system. VCSQI has demonstrated that improving quality reduces cost. For 

example, using evidence-based guidelines, VCSQJ has generated more than $43 million in 

savings through blood product conservation efforts and more than $20 million by providing the 

best treatment to patients with atrial fibrillation at the right time. 

Comments 

On behalf of STS, I would like to thank you for your very thoughtful proposal. The Society is 

particularly grateful that our endorsement of specialty-specific processes for determining quality 

and efficiency that rely on risk-adjusted outcomes (using registry data and associated quality 

measures) has resonated with the committees of jurisdiction and has a prominent role in your 

discussion draft. STS wishes to commend this Committee and your colleagues on the Ways and 

Means Committee for taking the first steps toward meaningful physician payment reform. STS 

has provided substantial comments on the concept document released by the Committees on 

April 3 that we submit here for the record. 

Access to Administrative and Outcomes Data 

Since survival and resource utilization information is such an important part of the outcomes for 

cardiothoracic surgery quality improvement efforts, we urge that steps be taken to insure these 

registries have access to administrative data from CMS (and, hopefully, other payors) both for 

episode of care and longitudinal follow-up, as well as outcomes (death) data from the Social 

Security Administration or another, accessible source. It is imperative that SGR reform 

legislation address this foundational issue. 
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The ability to link clinical data with administrative data has opened up important new ways to 

assess the effectiveness of treatment options, and has offered new avenues for medical research. 

Clinical data yield sophisticated risk-adjustment assessments, while administrative data provide 

information on long-term outcomes such as mortality rate, readmission diagnoses, follow-up 

procedures, medication use, and costs. In addition, linking clinical registries to the Social 

Security Death Master File (SSDMF) once allowed for the verification of "life status" of patients 

who otherwise would be lost for follow up after their treatment. 

The outcomes information derived from these data sources helps physicians educate today's 

patients and families so that they can play an active and infonned role in the shared decisionmaking process. Valid and reliable outcomes data give patients confidence in their medical 

interventions and demonstrate to patients and their families the durability and long-term risks 

and benefits of medical procedures based on real-life, quantified experience rather than abstract 

concepts. 

Unfortunately, CMS MEDPAR data have only been available for use in conjunction with the 

STS National Database on a project-by-project basis. Further, in November 2011, the Social 

Security Administration rescinded its policy of sharing state-reported death data as a part of the 

SSDMF. There are continuing efforts to further restrict access to the SSDMF so as to protect 

those listed in the file from identity theft. 
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Balanced against these legitimate privacy concerns are the many advantages oflinked 

administrative and outcomes data when placed in the right hands, with adequate protections in 

place. It is important to note that STS, through its contracts with the Duke Clinical Research 

Institute, maintains the patient identifier data separately from the actual clinical and other 

demographic data, and the only patient level identified information that ever leaves the database 

is simply that the patient has a record in the database. When combining records with outside 

sources, patient identification information is matched against other records, such as those in the 

SSDMF. The follow-up information is returned from external entities and linked back to the 

records in the de-identified database. The externally derived data are used to supplement the data 

in the individual record, but these clinical, patient-level data never leave the database except in 

de-identified form. 

Improving Care through Collaboration or Competition 

With its nearly 25 years of experience providing the STS National Database, STS has 

considerable expertise in how a data collection and physician feedback mechanism affects 

surgical practice. For that reason, we have made specific recommendations to the Committee 

about the level of attribution at which data should be collected and incentives should be applied. 

In general, our approach to these issues is to use the tools available to facilitate collaboration and 

raise the bar for the entire specialty of cardiothoracic surgery. 

If a quality-based payment system is designed to operate on the individual physician level, we 

fear that intra and inter-hospital cooperation and sharing of best practices will suffer. 

Additionally, from a purely statistical perspective, it is virtually impossible to distinguish 
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different levels of performance between one clinician and another because the total number of 

patients / outcomes / events created by the individual practitioners is far too small to achieve any 

meaningful interpretation. Placing incentives at a higher level can encourage collaborative 

learning and quality improvement that should be inherent aspects of professionalism. 

Finally, placing the focus on the individual practitioner or certain specialties detracts from the 

team approach to patient care that always has been the hallmark of our specialty (e.g., the heart 

team, the cancer team, etc.). In order for such a team to function at its highest level, there must 

be shared responsibility for patient care and patient outcomes. Assessing care quality at the 

institutional, regional, or national level allows the component parts of the heart team to share 

accountability, ensuring the patient receives the best care from the appropriate health care 

provider. 

Building Critical Registry Infrastructure 

STS is particularly grateful to this Committee for your recognition of the utility of clinical 

registries in pursuit of a pay-for-quality physician payment system. To that end, we recognize 

that Congress faces a challenge in that many specialties do not yet have the ability to collect 

clinical data, develop risk-adjusted quality measures, and implement physician feedback and 

quality improvement programs. That said, we hope that implementation of a pay-for-quality 

program will not have to wait for all of medicine to be at the same place at the same time. We 

believe that early innovators who are able to enter into Phase II should be able to reap some 

reward for their efforts. For that reason, we recommend that policy makers consider ways to 

reward providers for incremental steps towards these quality assessment and improvement goals 
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Page 8 

while allowing those medical professionals whose specialties that already have the requisite 

infrastructure in place to engage in this new system as soon as possible. 

Doing so will provide an incentive for others to move in a similar direction more quickly. 

Importantly, however, we believe that such a program can be structured so that physicians whose 

specialties are taking steps towards full scale implementation can reap some rewards. Short, 

medium, and long term infrastructure, measure, and quality assessment benchmarks should be 

set up as intermediate goals. For example, incremental steps towards Phase II readiness can 

include reporting of data to a clinical database und~r construction, working on various "Clinical 

Improvement Activities" as defined in the Committees' concept document, and receiving 

feedback on quality measure performance (even while such measures are being considered for 

approval), among others. 

Corollary Potential of Developing a Clinical Registry Infrastructure 

In appreciation of this Committee's work in favor of developing national clinical registry 

infrastructure, I wanted to point out for you some ofthe advancements in other aspects of health 

care policy facilitated by the STS National Database: 

Medical Liability Reform: With respect to the Committee's express intent to remain open to the 

discussion of medical liability reform, we believe that the proposal to develop a clinical registry 

infrastructure helps to lay the groundwork for tort reform that can protect patients and providers 

alike. STS believes that setting standards aligned with best practices identified by specialty 

societies is the best way to institute meaningful medical liability reform. Quality measurement 
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and data on clinical risk can be used to reduce lawsuits and the cost ofliability insurance, and (0 

restore balance to the justice system. 

Public Reporting: STS launched a Public Reporting Initiative in January 2011 in collaboration 

with Consumer Reports. As of March, 2013, 41 % of Database participants voluntarily report 

their results for Coronary Artery Bypass Oraft (CABO) and/or aortic valve replacement on the 

Consumer Reports or STS web sites. STS is universally regarded as the medical professional 

society leader in these activities. 

Medical Technology Approval and Coverage Decisions / Appropriate Use Criteria: The TVT 

RegistryTM is a benchmarking tool developed to track patient safety and real-world outcomes 

related to the transcatheter aortic valve replacement (T A VR) procedure. Created by STS and the 

American College of Cardiology, the TVT Registry is designed to monitor the safety and 

efficacy ofthis new procedure for the treatment of aortic stenosis. The TVT Registry was 

instrumental in facilitating the approval and coverage with evidence development of new 

medical technology, helping to bring this technology to the marketplace safely and efficiently. 

Comparative Effectiveness Research: The Patient Centered Outcomes Research Institute has 

recognized the value of "observational research" using clinical registries to fulfill its mission. 

Further, registries such as the TVT Registry can be developed and augmented to collect real time 

data to measure outcomes in different patient populations in real time. We believe that 

comparative effectiveness research can help physicians, in collaboration with patients and 

families, to provide the right care at the right time, every time. 
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Detennining Value of Physician Services: Congress should encourage CMS to use real, clinical 

data on procedural time and hospital lengths of stay collected via a clinical registry rather than 

time estimates which distort the relativity ofthe fee schedule. STS has used the time data from 

the STS National Database as the basis for relative value recommendations to the AMA Relative 

Value Update Committee. Unfortunately, the use of this type of real data has been resisted by 

CMS with the rationale that other specialties are not able to provide comparable data. 

Conclusion 

With the Congressional Budget Office's current Budget and Economic projections for 2014-

2023, it is clear that Congress must act now while the cost of SGR repeal is significantly lower. 

Although expected growth in Medicare spending has slowed, there is no guarantee that the trend 

will continue. Congress has the opportunity to take SGR off the books at a significantly reduced 

cost and we cannot afford to let this opportunity slip by. We urge Congress to act and support the 

current effort by this Committee to draft legislation for that purpose that recognizes and attempts 

to leverage the power of clinical registries. STS wishes to thank you for the collaborative nature 

of your process thus far, and requests that you move forward with continued openness to 

stakeholder input. 

Further, inasmuch as those who currently participate in the STS National Database may already 

be able to meet the provisions in your proposal as outlined, we welcome the opportunity to get 

started. Understanding that others will need to develop the infrastructure to support such a 

program, it is our hope that specialties will be able to jump into the pay-for-quality world when 
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they are ready, rather than waiting for all of medicine to get to the same place at once. To that 

end, STS has valuable experience in registry development that we are able to share with those 

specialties undertaking the task of building a registry now or in the future. 
82 

Mr. PITTS. And now recognize Dr. Foels 5 minutes for an opening 

statement. 

STATEMENT OF THOMAS J. FOELS 

Dr. FOELS. Good morning, Chairman Pitts, Ranking Member 

Pallone, and members of the Subcommittee on Health. On behalf 

of Independent Health—— 

Mr. PITTS. Would you please turn the mike on? Thank you. 

Dr. FOELS. Chairman Pitts, Ranking Member Pallone, and members of the Subcommittee on Health, on behalf of Independent 

Health I appreciate this opportunity to testify before you today. My 

name is Dr. Tom Foels. I am chief medical officer at Independent 

Health, which is a not-for-profit health insurer, serving over 

400,000 members in Medicare, Medicaid, and commercial insurance 

in the Buffalo metropolitan area of Western New York. 

Independent Health is nationally recognized for its quality of 

services and customer satisfaction. We have consistently ranked 

among the top 10 percent of health plans nationally for quality 

based on the National Commission for Quality Insurance. Independent Health shares the belief that the replacement of the SGR 

with a viable Medicare physician payment policy is critical to ensure that the Medicare program will be available for generations 

to come. We believe that it is time to replace the fee-for-service system with a system that rewards quality outcomes and efficiency. 

Now, while I represent Independent Health, I am also here with 

the collaborative voice of my colleagues at the Alliance of Community Health Plans, a group of not-for-profit community-based plans 

dedicated to improving the health of its members, the health of the 

communities in which they live and work, as well as to ensuring 

affordability of coverage. 

And finally, I speak today as a primary care physician with over 

30 years of clinical and administrative experience. For the past 17 

years I have held various senior positions at Independent Health, 

the last four of which as chief medical officer. During that time, I 

have been deeply involved in our efforts to improve quality and affordability of health care for our community. 

My experiences as a physician have taught me that transformational change is difficult, regardless of its merits. I understand the skepticism and reluctance of some physicians because I 

have, at times, shared it as well. But I have also come to understand that important changes need to be made now that will benefit both physicians and patients and that the transition to a valuebased payment system is both desirable and workable. 

Our upstate New York community, provider community, is typical of so many communities across the country with an abundance 

of independently practicing, non-aligned primary care and specialty 

care providers and hospitals. Recognizing the desire of physicians 

to retain their independence, Independent Health has designed its 

programs in a way that has led to a virtually integrated model of 

providers. Independent Health has helped pioneer efforts in quality 

improvement, primary care design, and implementation of alternative payment systems. 

Much of our success is based upon the deep trust and collaboration we have purposely fostered with our provider community 

83 

throughout many years of working together. We believe there are 

valuable components of our quality, efficiency, and effectiveness 

programs that are potentially scaleable and transferrable to other 

communities beyond our own. 

Independent Health’s approach toward developing improved systems of care are based upon several guiding principles, but most 

importantly they are based upon the assumption that primary care 

plays a pivotal and foundational role in the transformation to an 

improved system. 

Independent Health is very excited about a recent development 

of a new model of primary care and reimbursement which we call 

Primary Connections. In this program, primary care practices that 

are certified patient-centered medical homes are reimbursed not 

under fee for service, but a hybrid payment system that includes 

a prospective, population-based payment, a quality bonus, and a 

shared savings program that rewards providers for reducing the 

total cost of care. 

The collaborative also develops strong relationships between primary care providers and specialists who compete for primary care 

referrals based upon transparent data, profiling their quality, and 

cost efficiency. 

I would like to briefly share two stories from our Primary Connection model, one that represents the past and one that represents and illustrates the experience of a patient and physician 

under the Primary Connection model. 

Imagine the year 2010, a 70-year old man with a past history of 

diabetes, hypertension, and coronary disease contacts his primary 

doctor early one morning on a Monday complaining of chest pain 

while climbing stairs at home. He is seen in less than an hour by 

his primary, where an EKG shows suspicious findings. His doctor 

sends him to an emergency room where he is first seen by a triage 

nurse, then a physician assistant, then an ER physician. No provider examining him has access to his medical records. His EKG 

is repeated; blood work and diagnostic studies are performed. A decision is made to admit him overnight to monitor and observe his 

condition. He is discharged the following morning and given instructions to follow up with his primary. The primary does not receive a report from the hospital for at least 3 days. Costs would 

well exceeds $4,000. Care would be fragmented. Handoffs would be 

poorly coordinated. And the patient and family would be worried, 

anxious, and afraid. 

The year is now 2013. Under Primary Connections, its patientcentered care, its reimbursement system based on quality outcomes 

and cost effectiveness, another scenario unfolds. It is again 10:00 

a.m. in the morning and the patient presents to the physician’s office. Now unlike the previous scenario, the physician immediately 

contacts his preferred collaborating cardiologist and forwards the 

EKG to his review. This preferred cardiologist has demonstrated 

his efficiency, quality, and clinical outcomes and is chosen because 

of that and because the primary works under a reimbursement 

model that incents collaboration and new forms of patient management. 

After reviewing the studies the cardiologist makes accommodations for the patient to be seen. The same blood work and diagVerDate Nov 24 2008 11:36 Dec 03, 2013 Jkt 037690 PO 00000 Frm 00089 Fmt 6633 Sfmt 6633 F:\MY DOCS\HEARINGS 113\113-50 CHRIS
84 

nostic testing that might otherwise have been performed in the ER 

is completed in the cardiologist’s office. The patient and family are 

advised he is not having a heart attack. The cardiologist and primary speak by phone to coordinate care and follow-up. Later that 

afternoon, the primarycare coordinating nurse calls the patient at 

home to be certain he is well and asks if there are questions. Total 

cost of care, $1,200; care coordinated and efficient; communication 

immediate and complete; patient and family fully informed. Primary care physician is rewarded. 

In conclusion, I look forward to sharing with the subcommittee 

the journey Independent Health and its physician partners are now 

taking to arrive at this efficiency and effective system of care, as 

well as our longstanding successful programs to promote quality. 

Mr. PITTS. Chair thanks the gentleman. 

[The prepared statement of Dr. Foels follows:] 

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85440.067

Hearing on Reforming SGR: 

Prioritizing Quality in a Modernized Physician Payment System 

Committee on Energy and Commerce 

Subcommittee on Health 

United States House of Representatives 

Wednesday June 5, 2013 

Statement of Thomas J. Foels, MD MMM 

Chief Medical Officer 

Independent Health 

Buffalo, New York 
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Independent Health (IHA) is an innovative, health solutions company with a passionate dedication to 

achieving its mission of providing health-related products and services that enable affordable access to 

quality health care. To control the unsustainable trend of rising health care costs, Independent Health 

has created wide-ranging community partnerships with physicians and health providers intended to 

achieve the triple aim of improved health, better care, and lower costs. 

IHA has helped pioneer efforts in quality improvement, primary care redesign, and implementation of 

alternative payment systems. Our provider community is typical of many communities across our 

country, with an abundance of independently practicing, non-aligned primary care and specialty care 

providers and hospitals. We believe there are valuable components of our quality, efficiency, and 

effectiveness programs that are potentially scalable and transferrable to other communities beyond our 

own. In addition, we have identified a set of critical success factors based upon our experiences that we 

also believe will help guide innovation on a national level. 

Included in this document are detailed descriptions of the various programs IHA has successfully 

implemented impacting quality and effectiveness of care, as well as a description of our efforts to build 

improved systems of care based upon the patient-centered medical home model (PCMH) combined with 

a novel, hybrid reimbursement program that aligns payment with key PCMH design elements. 
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About Independent Health 

Independent Health (IHA) is a regional not-for-profit plan providing health benefits and services to 

nearly 400,000 individuals in an eight-county region the Buffalo metropolitan area of Western New York. 

Its affiliated physicians include an open network of approximately 1,200 contracted primary care and 

2,300 contracted specialty physicians, with the vast majority practicing in independent small singlespecialty group practices or solo practice settings. Two dominant hospital systems provide inpatient and 

outpatient care services and remain largely unaligned and independent of the physician community. 

IHA is nationally recognized for the quality of its services and extraordinary customer satisfaction. IHA is 

currently ranked among of the top 10% of health plans in the nation for quality by the National 

Commission for Quality Assurance (NCQA) in its Health Insurance Plan Rankings for commercial, 

Medicare, and Medicaid products. IHA has achieved and retained a 4.5 Medicare STAR quality ranking 

since the inception of the quality recognition program. In addition, IHA was named as the top health 

plan in the nation for customer service for 2009 and 2010 according to the NCQA Quality Compass® and 

currently is the nation's highest scoring health plan in customer satisfaction according to the J.D. Power 

and Associates' 2013 Member Health Insurance Plan Study5M. 

Independent Health works to create partnerships and develop initiatives throughout our community to 

provide a balanced approach to improve quality - accompanied by efforts to contain costs, eliminate 

wasteful spending, and enhance efficiencies. Much of IHA's success is based upon the collaboration and 

trust the plan has fostered with the provider community throughout its history. 
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Guiding Principles 

While the Affordable Care Act (ACA) provides a framework for reform, we believe the most sustainable 

solutions for health care reform will continue to take place at the local level. The following are guiding 

principles that have governed IHA's approach toward developing improved systems of care, enhanced 

quality, and greater health care affordability: 

Substantive and sustainable improvement in quality and affordability of the American health 

care system will require movement away from traditional fee-for-service (FFS) 

reimbursement systems. 

Primary Care plays a pivotal and foundational role in the transformation to a sustainable 

high-quality, affordable health care system. Navigation of patients through a complex 

health system is best coordinated by providers with broad primary care based professional 

training who can serve as a "medical home" to their patients. Primary care is currently 

under-resourced and over-burdened. Immediate efforts should be made to strengthen and 

redesign critical components of primary care to help ensure its future success. 

Patient care is inherently "team-based." Management of preventive health and chronic 

disease is a shared accountability within both office-based teams and across virtual teams of 

care providers in mUltiple settings. Traditional fee-for-service (FFS) reimbursement and 

early first-generation quality incentives do not sufficiently align performance within or 

among care teams of diverse providers. 

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• Historically, highly integrated delivery systems (IDS) have demonstrated the ability to 

provide exceptional levels of coordinated, high quality, cost effective patient care. In many 

cases, such systems have evolved over decades and have proven difficult to replicate or 

sufficiently scale. "Virtually integrated networks" of collaborating providers have the 

potential to significantly close the performance gap in many communities over a shorter 

time. Primary care remains centric to the development of such virtually integrated systems 

and efforts should be made to align incentives among and within primary care practices to 

fulfill this need. 

• No singular payment system is sufficient to simultaneously promote quality, efficiently, and 

effectiveness. A hybrid approach that balances the best attributes of various payment 

systems, based upon operational ease and transparent methodologies, is most likely to be 

effective at aligning incentives with performance. 

• Successful transformation of the delivery system will be dependent upon accurate, 

actionable, and timely reporting, performance data transparency, and resources deployed 

to help educate and promote "improvement literacy" and care systems redesign with the 

provider community. 

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Experiences and Successful Programs at Independent Health 

Quality Enhancement and Pay-for-Performance 

IHA was among the pioneering health plans to initiate quality based reporting and payment incentive 

programs. Our first generation programs, which began in 2000, were primary care focused, derived data 

exclusively from administrative claims, and included quality process measures and to a lesser degree, 

utilization measures. The program was collaboratively designed with the aid of a physician advisory 

panel, and included meaningful monetary incentives (i.e. up to 10% of the value of the physician's 

current fee schedule), attainable performance thresholds, actionable reporting, and "improvement 

literacy" provided by a dedicated team of health plan Practice Improvement Consultants. Within the 

ensuing three years of this program, significant improvements were achieved in preventive cancer 

screening and clinical process measures related to diabetes. 

As the limitations of claims-based administrative data and focus on process measures became apparent, 

IHA began a second-generation quality reporting and payment program in 2003. This program, named 

Practice Excelience'M, supplemented administrative data with clinical data derived from the physicians' 

medical record, and included outcome measures for diabetes, hypertension, cardiovascular risk 

management, as well as expanded process measures for asthma, emphysema, heart failure, and 

depression. Unlike the previous program, Practice Excelience'M included pay-for-participation, 

rewarding engagement activities with Practice Improvement Consultants, as well as pay-forperformance measured against fixed performance thresholds. The financial incentive opportunity was 

enhanced to 15% ofthe primary care physician's FFS revue. 
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Within a 5-year period, significant improvement was demonstrated in multiple metrics, particularly 

those related to diabetes care. For example, blood glucose control (A1C level at goal) increased 67% 

above baseline and lipid management (LDL at goal) and hypertension management (Blood Pressure at 

goal) each increased nearly 50% over baseline. Concurrently, IHA's national HEDIS (NCQA-Health 

Effectiveness Data and Information Set) rankings for comprehensive diabetes care rose from the 50th 

percentile nationally to the 90th percentile of comparable health plans. IHA currently maintains the 

highest quality ranking in the northeastern United States for comprehensive diabetes care based upon 

HEDIS scoring. 

IHA recently began a third generation quality reporting program to measure performance of chronic 

medical conditions in and across multiple care settings. Recognizing the prevalence of diabetes in 

Western New York, and diabetes as a critical risk factor contributing to mUltiple cardiovascular 

conditions, we have begun reporting diabetes process measures with both cardiologists and their 

referring primary care physicians. Among diabetic patients currently referred and actively managed 

within cardiology offices, a surprising 16% lack evidence of blood glucose testing (A1C) within the past 

year, 18% lack a blood lipid testing, and 36% lack appropriate medication management of coexisting 

kidney disease. 

Cardiologists were initially resistant to assume shared responsibility for these diabetic performance 

metrics, insisting that clinical management of diabetes is the responsibility of the primary care physician. 

After meetings and discussions with both cardiologists and primary care physicians (PCP), cardiologists 

have begun to collaborate with PCPs to co-manage these important clinical indicators. Cardiologists are 

7 
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now more actively engaged in addressing both quality and efficiency within their practices, especially 

given IHA's Primary ConnectionsSM program, which rewards specialists that achieve better outcomes for 

their patients. This program is described more fully later in the document. 

Critical Success Factors: 

Physicians should be involved in the design, development, and monitoring of quality 

based reporting and incentive programs. Early buy-in of physician attribution 

methodology, measurement selection, performance thresholds, and design elements 

for actionable reporting is critical. 

Quality metrics selected should be based upon community health priorities. Measure 

and incent quality based upon metrics that will have a meaningful impact, not simply 

those easy to measure. 

Primary care and specialty care providers can be held mutually and collectively 

accountable for certain quality performance metrics that cross disciplines. 

A combination of accurate performance data, meaningful incentives, and provider 

education ("improvement literacy") has proven a powerful formula for success. 

8 
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Patient-Centered Medical Home and Payment Reform 

IHA has had a long and successful history of collaboration with the region's physician community, 

particularly the primary care community. In 2008, the health plan initiated discussions with key 

physician advisors regarding how to successfully rejuvenate and transform primary care to become a 

central element in the redesign of the local health care delivery system. Concurrent with these efforts, a 

broader national dialog was emerging regarding the concept to the "patient-centered medical home" 

(PCMH) and the National Commission for Quality Assurance (NCQA) was completing development of a 

certification process for such practices. 

Following the development of design objectives and eligibility criteria, IHA accepted 16 primary care 

practices (120 physicians) into its PCMH Pilot Program in January 2009. An important element of PCMH 

was a proposed alternative reimbursement system that reduced reliance upon traditional FFS 

reimbursement and, instead, placed emphasis on a prospective risk-adjusted care coordination fee paid 

on a monthly per-member per-month (pm pm) basis. In addition, existing quality incentive programs 

were enhanced and carried higher performance thresholds. The intent of this payment transition was to 

better recognize and reward team-based care within the primary care office, reward and incent 

exceptional clinical quality, and transition away from the requirement for care to be reimbursed solely 

upon office based face-to-face encounters. 

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Evolut!on of PCMH Re!.mbllrsement Mode! 

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Physicians were surprisingly resistant to the proposed rapid transition away from FFS. Therefore, at the 

formal launch of IHA's PCMH Pilot Program in 2009, FFS was retained and enhanced "earned incentives" 

for quality were established. The earned incentives were based upon attaining high-threshold quality 

goals, completion of certification of the practice through the NCQA-PCMH program, and other factors 

including improved patient experience of care. Overall, practices had the potential to earn up to 130% of 

their former base revenue. 

During the initial 24 month period, all practices attained the highest level of NCQA-PCMH certification 

and demonstrated moderate trends toward increased efficiency of total cost of care for the populations 

10 
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they served. Quality performance measurements accelerated at a more rapid pace than other primary 

care practices not engaged in the PCMH Pilot Program. It proved difficult, however, for practices to 

engage in development ofteam-based care and provide substantive non-visit care, despite ongoing 

education and practice management consultation. There was growing awareness that retaining FFSbased reimbursement was proving a strong deterrent to practice innovation. 

Following the completion of the initial PCMH Pilot Program (2009-2010), additional primary care 

practices meeting eligibility criteria were recruited to participate in an enhanced PCMH program that 

IHA developed called the Primary Connections SM. During the following 18 month period (2011-June 

2012), the physician advisory panel accepted the need to transition away from a FFS based 

reimbursement system. During this period, FFS reimbursement was retained only for those services for 

which enhanced utilization was desirable, including preventive office visits, immunizations, and select 

office-based testing. The remaining monetary balance of the FFS revenue was converted, in budgetneutral fashion, to a prospective risk-adjusted pm pm payment. In addition, the retrospective incentive 

for quality and NCQA-PCMH recertification was retained and enhanced. Overall, participating PCMH 

practices had the potential opportunity to earn 150% more than non-participating primary care 

practices. 

During the ensuing 18 month period, quality performance continued to advance and total cost of care 

diminished. Since the inception of the PCMH program in 2009, aggregate total cost of care for members 

assigned to PCMH practices has decreased 3.4% compared to peer averages. 

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Although PCMH practices had begun to impact total cost of care, the majority of medical expenses arise 

outside the domain of their primary care practices with expenses related to specialty care, hospital care, 

and laboratory, radiology and other ancillary services. Primary care reimbursement failed to reward 

activities related to engagement with the specialty community, development of collaborative programs 

to coordinate care across disciplines, or efforts to create programs to reduce potentially preventable 

hospital admissions and readmissions. 

With this understanding, IHA developed a new hybrid reimbursement program for Primary 

ConnectionsSM practices beginning in July 2012. This new reimbursement approach now includes a 

shared savings component that provides an opportunity for practices to earn up to 200% of their former 

base revenue of four years earlier. As part of this new approach, a funding pool is established 

representing 65% of any saving on total cost of care compared to the previous year's expenditures of 

the practices. Earned shared savings therefore represent the collective as well as individual efforts of 

participating PCMH practices to enhance efficiency and effectiveness of care. 

The development of the shared savings model has had a dramatic impact on the interaction of PCMH 

practices with one another (peer-to-peer collaboration), as well as generating meaningful engagement 

with specialists. Since shared savings opportunities are dependent upon the performance of specialists, 

collaborative efforts with cardiology, gastroenterology, neurology, radiology, and orthopedics with the 

referring primary care physician have emerged. This engagement has included efficiency and quality 

data reporting of specialty practices with primary care practices, as well as complete transparency 

among and within the specialty community. Specialty practices have now begun to compete for primary 

care referrals based upon published efficiency and effectiveness scores, and work within their practices 

12 
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to eliminate non-value added procedures and tests, work to address avoidable hospital admissions and 

readmissions, reduce duplicative services and testing, prescribe generic medications where appropriate, 

and enhance service attributes, care coordination, and communication with referring primary care 

physicians. 

A "ripple effect" of improvement efforts is now evident across the region's competing hospital systems 

as well. Since differences within negotiated hospital contract rates directly impact those specialties that 

are heavily hospital-based, high cost facilities risk disenfranchisement by specialties eager to improve 

their published efficiency indexes and willing to relocate their faCility-based procedures and admissions 

to other more cost-effective hospitals. 

As a virtual high performing network of primary and specialty care physicians and hospitals is now 

beginning to evolve, IHA is able to design and market tailored network insurance products at attractive 

premiums to employers and individuals eligible forthe Exchange. 

Critical Success Factors: 

FFS remains a valuable mechanism to promote utilization of important and 

potentially underutiJized services, including preventive services. 

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Prospective, risk-adjusted, population-based care coordination fees (distributed 

on a pmpm basis) give practices the freedom to tailor their care services to 

member needs and frees them from dependency upon face-to-face interactions. 

• Virtual high-performing networks have the potential to emerge organically 

under the influence of properly designed alternative payment systems. Novel 

reimbursement programs focused on greater responsibility of the primary care 

team can have important ripple effects across the broader delivery system. 

Shared savings programs, even when limited to primary care practices, can have 

a dramatic impact upon the engagement of other important segments of the 

provider community (specialists and hospitals) and help communities move 

toward greater efficiently and effectiveness of health care delivery. 

• Trust, transparency, and physician engagement in design elements of 

alternative reimbursement programs is critical for their successful adoption. 

Existing models of care delivery and reimbursement are potentially scalable and 

transferable to other settings and can be more rapidly deployed based upon 

know critical success factors identified in early pilot programs. 

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Concluding Remarks 

Independent Health supports the goals of the House Committee on Energy and Commerce to reform the 

SGR and we applaud the bi-partisan congressional efforts to shift Medicare physician payment away 

from fee-for-service and toward payment that rewards performance, quality and value. Given 

Medicare's prominence as the single largest payer in the nation, fixing the SGR could become a powerful 

force in aligning incentives in a way that is consistent with the work already underway in the commercial 

market. 

IHA has pioneered efforts in quality improvement, primary care redesign, and implementation of 

alternative payment systems within a provider community that is typical of many communities across 

our country, with an abundance of independently practicing, non-aligned primary care and specialty 

care providers and hospitals. We believe there are valuable components of our quality, efficiency, and 

effectiveness programs that are potentially scalable and transferrable to other communities beyond our 

own. In addition, we have identified a set of critical success factors based upon our experiences that we 

also believe will help guide innovation on a national level. 

On behalf of Independent Health, I again thank the Subcommittee on Health forthe opportunity to 

present these perspectives. We look forward to continuing to support and assist in this important work 

in the months and years ahead. 

15 
100 

Mr. PITTS. That concludes the opening statements. We will now 

go to questions from the members. I will begin the questioning and 

recognize myself for 5 minutes for that purpose. 

Dr. Damberg, the proposed SGR revision has an initial phase 

with a period of payment stability, while quality-measure development takes place concurrently. What is an appropriate period of 

payment stability, in your opinion, in order to develop and vet 

measures and build the necessary quality infrastructure? 

Ms. DAMBERG. As I noted in my testimony, there are an array 

of measures that already exist in primary care, and those are ready 

for market. So that transition could begin much faster than on the 

subspecialty side. As one of the other panelists indicated, some of 

the clinical subspecialties have taken significant steps to identify 

clinical process and outcome measures, and I think that those 

should be leveraged in the near term. And I think in the area 

where measures currently do not exist, and that space is pretty 

vast for the subspecialists, that process is probably going to take 

3 years to bring measures to market. 

Mr. PITTS. Thank you. 

Dr. Rich, considering the different levels of provider readiness, 

how do we balance the need for a stable period enabling providers 

to build and test the necessary quality infrastructure while still 

incentivizing early innovators to move to Phase II with opportunities for quality-based payment updates? 

Dr. RICH. So I would agree that a 3-year period for the embryonic 

novice would be important because it takes that long to develop 

your measures, get them vetted through an organization that 

would approve them, and then actually to start collecting data and 

look at it and using them effectively. 

For those who, like us, who have measures already and we are 

using them already, I would suggest a tiered incentive program 

whereby the new payment reform would provide incentives to develop databases. If they only start out early with structural and 

process measures, and then develop outcome measures, that is fine. 

But those who have outcomes measures can start early with payfor-performance pilots or pay-for-performance programs as we did 

in Virginia with WellPoint/Anthem, as well as in the public sector. 

Mr. PITTS. OK. 

Mr. Kramer, public feedback has reinforced the concept that it is 

essential for providers to receive performance feedback in order to 

make appropriate changes in practice improvements. To the survivor of the pickup basketball game, what does a meaningful, timely feedback process look like for providers, and what are adequate 

performance feedback intervals? 

Mr. KRAMER. We strongly support the principle of providing feedback to physicians and other providers on the quality and affordability of the care that they provide. That should be an integral 

part of this redesigned payment system. And to the extent it is possible, we should move in the direction of having real-time feedback 

so that information that is embedded in electronic health records 

is accumulated and fed back to physicians on a regular basis. 

I worked for many years at Kaiser Permanente, one of the pioneers in the development of electronic health records. That kind of 

ongoing feedback to physicians was essential. I understand that 

101 

many systems will take a while to get to that point, but that is 

what we should strive toward. In the interim, we should try to provide feedback as frequently as the information is meaningful in 

terms of volume of services that provides an adequate database for 

evaluation over quality. 

Mr. PITTS. Dr. Foels, you state in your testimony that one of the 

guiding principles of IHA are, quote, ‘‘Substantive and sustainable 

improvement in quality and affordability of the American 

healthcare system will require movement away from traditional 

FFS reimbursement systems.’’ Can you explain why in your opinion 

FFS Medicare undercuts quality and affordability in our healthcare 

system? 

Dr. FOELS. Yes, thank you. 

Yes, we believe that fee-for-service reimbursement does little to 

reward quality or recognize efficiency. It varies among providers by 

great degrees. It also inhibits collaboration across provider communities. Ultimately, the care of a patient is that of a team. It is 

based on teamwork within a single practice, and it is dependent 

upon a team across multiple specialties. 

And fee for service as currently visioned and currently practiced 

does not promote any collaboration among providers, and hence we 

strongly believe that a new system of reimbursement that may involve some degree of hybridizing the best parts of multiple ways to 

reimburse may be much more effective. 

Mr. PITTS. The chair thanks the gentleman. 

Now recognize the gentlelady, Dr. Christensen, for 5 minutes for 

questions. 

Mrs. CHRISTENSEN. Thank you, Mr. Chairman. 

And thank you for your testimony. 

As an African-American physician who practiced for more than 

20 years, I know that many racial and ethnic minority providers, 

providers in rural areas, as I once did, work in communities and 

treat patients who have long been underserved by the healthcare 

system and detrimentally affected by the social determinants of 

health that create, sustain, and even exacerbate the health disparities. As a direct consequence, some patients simply present with 

more challenges than others, and that needs to be taken into account as we develop these systems. And so as we seek to assess 

provider quality and efficiency in a reformed Medicare payment 

system, we will undoubtedly struggle with how to account for these 

gaps. 

So how should we be thinking about addressing these racial, ethnic, gender, and rural disparities as we move to incorporate quality 

performance measurement into a new Medicare physician payment 

system, and how can we assure that the Medicare payment reforms 

do not leave those providers who serve the Nation’s most medically 

and financially needy in harm’s way by ignoring the upstream variables that directly affect patient outcomes? 

So anyone can answer, but maybe I would begin with Dr. 

Damberg by asking her if her pay for improvement along the gradient begins to address that. 

Ms. DAMBERG. I think absolutely. And as I noted, the way in 

which you structure the translation from actual performance to the 

payment can be modulated along that performance curve, such that 

102 

you more heavily incentivize folks who are at the lower end of performance, and generally those folks are struggling with some of the 

very issues you identify. 

So I think that the primary thing that you want to try to avoid 

happening is you are going to under-resource those providers. So 

allowing them to earn incentives for each increment of improvement I think will help mitigate that problem. 

The other thing that I think is really important is trying to align 

incentives across providers. And I think if you look at what is going 

on in ACOs that are really linking providers across the continuum 

of care, as well as with social service agencies in the community, 

because I think there is recognition that it is not just health care 

that influences whether somebody comes back into the system. And 

so, again, I think there is really sort of an elephant in the room 

around larger payment reform, not just working at the margins, 

which is what incentives overlaid on fee for service really look like. 

And so if you look at the Blue Cross Blue Shield of Massachusetts Alternative Quality Contract, where they have aligned incentives, it is a global payment, providers have worked very hard and 

have closed the disparities gap. So I think there are models out 

there that really have demonstrated that they can improve care for 

these disadvantaged patient populations. 

Mrs. CHRISTENSEN. Dr. Rich? And I was going to ask the Thoracic Surgeons and maybe Independent Health, have they grappled 

with this and addressed it? 

Dr. RICH. And the STS has long recognized that there are disparities in care. In our database we collect data on Afro-Americans, 

Hispanics, as well as Asians. We look very carefully at disparities 

in care for women and for socioeconomic status. And my first answer or response is that we need to measure it and inform providers whether they are addressing these needs or not. 

I think to change it you could do what we did at CMS for hospitals and provide a disproportionate share payment, DSH payment, that allows providers to seek out the communities that need 

them the most, and to get an added incentive to their fee-for-service payment. 

Dr. FOELS. And if I might add, and build off the two previous remarks, I, too, am very sensitive to the fact of the gap in disparities, 

which is not closing nearly as fast as anyone feels comfortable. And 

I concur with Dr. Damberg’s comments that it is important to recognize that inner-city, urban, and rural providers have different 

starting points for their quality and they should not be punished 

for that. And there are scoring mechanisms and evaluation mechanisms, reporting mechanisms that would allow their incremental 

improvement and support. 

Mrs. CHRISTENSEN. Thank you. 

My time is almost up so I will yield back. 

Mr. PITTS. Chair thanks the gentlelady. 

Recognize Dr. Burgess 5 minutes for questions. 

Mr. BURGESS. Thank you, Mr. Chairman. 

Dr. Rich, thank you for being here. You are a practicing 

cardiothoracic surgeon, is that correct? 

Dr. RICH. Yes. 

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Mr. BURGESS. So when you drive to work in the morning, do you 

tell yourself, boy, I hope I am average today? 

Dr. RICH. No. 

Mr. BURGESS. No, you go to work to do your best work every day. 

Dr. RICH. That is right. 

Mr. BURGESS. This is why I have always had a little bit of trouble with the concept of pay for performance. We are goal-directed 

individuals as physicians. We always go to work to do our best job. 

We never go into a patient’s room expecting to be slightly above average, or hopefully not below average. No, we go in to do our best 

work. So we all need to recognize we are dealing with a highly motivated population of providers, and somewhat at our peril if we 

damage that motivation that exists amongst the Nation’s physicians. And that is why it is so important to get the SGR reform 

because it is damaging to the psyche of America’s doctors. 

Now, I woke up this morning to the paper who said that they 

were very dismissive of the hearing we have today. The quote in 

the paper is that the draft that we have in front of us doesn’t tackle some of the biggest outstanding issues, such as how to measure 

quality. So I really liked your comments. In your written testimony 

you said on behalf of the Society of Thoracic Surgeons, I would like 

to thank you for a very thoughtful proposal. And I agree with you. 

I think it is a thoughtful proposal. I think the committee and the 

committee staff have done a very good job of going to the provider 

community and soliciting their input as to what these performance 

metrics would be. Do you agree with that? 

Dr. RICH. Oh, absolutely. Having sat at CMS and seeing other 

thoughts and legislation coming out of here, I think this is probably 

the most thoughtful, well-rounded, and sought after for input proposals out there. I was really impressed at the questions and some 

of the principles that were out there regarding the SGR reform. 

Mr. BURGESS. Can you say that again for the press? You were 

very impressed? 

Dr. RICH. I think they did a great job. 

Mr. BURGESS. All right. Well, and let me just ask you, on the 

issue of CMS, you do reference in your testimony that it is so important that the registries have access to clinical data from CMS. 

CMS, as we learned over the past several weeks as they releasing 

some hospital data, I mean, they have got a lot of data, and it 

would really help you and your specialty in developing these performance metrics, it would really help you to have access to that 

data, is that not correct? 

Dr. RICH. Absolutely. We have access to data that is really financial data. There is a little bit of clinical data in the CMS database, 

but more financial. Now, when ICD–10 comes out there will be 

more clinical data. But bringing that financial data into the patient 

record and matching that with the clinical experience has been an 

enormously powerful tool for us in Virginia. We have been able to 

see how quality improvement reduces costs. We have been able to 

look at maintaining quality and reduce resource consumption and 

provide the same level or better levels of care. 

It is a very powerful tool to have, and access to it has been a little troubling recently. We are trying to do that on a national scale, 

104 

the STS is, and we are having difficulty because we have to go 

every time and ask for a special exception. 

Mr. BURGESS. So is that the bottleneck, the fact that you have 

to go every time and ask for the specific data? 

Dr. RICH. It is one of the bottlenecks. 

Mr. BURGESS. Are there other bottlenecks that you could identify 

for the committee. Because we would like to help you, we would 

like to facilitate that exchange of data, because I believe you are 

on to something, and I think when you do have the data sometimes 

you will discover things that you weren’t even thinking of as a way 

to embark on a cost-saving measure. So I want you to have the 

data and I want you to have access. 

Dr. RICH. No, I appreciate that. So another bottleneck has been 

getting the Social Security Death Index data. That has been shut 

down because of, I guess, legal issues. And so in the past we were 

always able to track our outcomes and look at those who have died 

and figure if we have done a good or a bad job, you know, if they 

have died 7 months later. So that is a bottleneck. 

Mr. BURGESS. It is a clinically identifiable endpoint, correct? 

Dr. RICH. Usually. Sometimes people argue about it. But—— 

Mr. BURGESS. Just before my time expires, and I may ask you 

in writing to get back to us with some of those bottlenecks. 

But, Dr. Foels, I need to ask you, you spent some time discussing 

the fee-for-service aspect of the system and why you don’t think 

that should endure. And yet, in your testimony, no singular payment system is sufficient to simultaneously promote quality, efficiency, and effectiveness. And I said in my opening statement, 

whatever we do here, it has to allow for the entire panoply of practice options that are out there, allow them to exist and to thrive 

and, in fact, flourish. 

So I would just tell you, I think the committee has done a good 

job as far as allowing a fee-for-service model to continue. As someone who has practiced OB-GYN, I mean, there is not a lot of Medicare practice in your average OB-GYN practice, but there is some 

and it is an important part. And if I have got to join an ACO or 

deal with bundled payments in order to continue to see those patients, I may well say enough is enough, and I am just going to exclude those patients from my practice. But if you allow me to have 

a fee-for-service model for compensation for those patients, I may 

be more apt to continue. And there are other examples I could give 

you, but in the interest of time, do you have a comment on that? 

Dr. FOELS. Yes, you raise several points, one being that we may 

need to embrace a variable model for those individuals, those organizations, those physician communities that want to move quicker 

and faster toward development of virtual high-performing systems. 

You also pointed out the fact that the, in my opening comments, 

that there is no singular payment system that isn’t without its benefits or its perversities, so trying to blend the best of all together 

is effective. 

One of the interesting footnotes in our experience is our application of the hybrid payment system to primary care physicians and 

its subsequent impact on specialty and hospitals that are still practicing under fee for service. And I would be welcome to describe 

that in further detail. But the takeaway message here is sometimes 

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altering a payment system within one sector of the provider system 

can have effective and beneficial impacts on other sectors that remain under fee for service. 

Mr. BURGESS. Thank you, Mr. Chairman. I will yield back. 

Mr. PITTS. The chair thanks the gentleman, and now recognizes 

the distinguished ranking member emeritus of the full committee, 

Mr. Dingell, for 5 minutes for questions. 

Mr. DINGELL. Mr. Chairman, I thank you for your courtesy. I 

commend you for holding this hearing. It is a fine example of good 

bipartisan, bicameral progress. And it is my hope that it will lead 

to repealing the fatally Sustainable Growth Rate, SGR, and replacing it with a system that makes good sense for our healthcare system and for our physicians. 

We have broad agreement on the goals and now we must come 

together in a bipartisan manner to work hard and find out what 

is the proper solution for this problem. 

These questions are for all of our witnesses and will be both 

friendly and mostly yes, or no. 

First question. At the end of 2012, Congress passed legislation to 

prevent a 26.5 percent reduction in physician payment rates. This 

short-term fix was signed into law last year and cost about $25.2 

billion. Is that correct? Yes or no? 

Dr. RICH. Yes. 

Mr. DINGELL. Thank you. I was afraid I wasn’t going to get a volunteer down there. 

This year, the Congressional Budget Office found the cost of 

freezing physician payments for 10 years is $138 billion, more than 

$100 billion more than their previous projection. I believe this demonstrates the urgent need for the Congress to act. 

Now, again, to each witness, do you believe that Congress should 

repeal and replace the SGR this year? 

Ms. DAMBERG. Yes. 

Mr. KRAMER. Yes. 

Dr. RICH. Yes. 

Mr. DINGELL. Sir? 

Dr. FOELS. Yes. 

Mr. DINGELL. Sir? 

Dr. FOELS. Yes, I think initiatives should begin. 

Mr. DINGELL. Now, in your analysis, did this system improve 

quality outcomes, yes or no? 

Ms. DAMBERG. Could you clarify which system? 

Mr. DINGELL. I am sorry? 

Ms. DAMBERG. Could you clarify which system you are referring 

to? 

Mr. DINGELL. Well, I am sorry. We will just lay this one on Dr. 

Foels and make that easier. 

Dr. Foels, did the system improve quality outcomes, yes or no? 

Dr. FOELS. I believe the existing fee-for-service system turns a 

blind eye to quality and efficiency. 

Mr. DINGELL. OK. Now, your Independent Health system recently implemented a system that shifts away from the traditional 

fee-for-service reimbursement. That is correct, isn’t it? 

Dr. FOELS. That is correct. 

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Mr. DINGELL. And in your analysis, you found that this new system did improve outcomes, right? 

Dr. FOELS. Yes, it did, medically. 

Mr. DINGELL. All right. Now, do you believe that the reforms 

made by the Independent Health are a good example that the Congress should or could follow when reforming SGR, yes or no? 

Dr. FOELS. Yes. 

Mr. DINGELL. Now, there are many other private groups across 

the Nation that are experimenting with innovative payment models 

which promote quality care over quantity of care in an effort to 

make our healthcare system more efficient. I heard a great deal of 

comment relative to this point today. And it is my feeling we 

should use these efforts as building blocks. Congress must ensure 

any new physician payment model does not work counter to other 

successful innovations that are already in place. 

Now, these questions are for all witnesses. Ladies and gentlemen, do you believe the Congress should look at the innovations 

and changes being made in the private sector when considering reforms to SGR? 

Ms. DAMBERG. Yes. 

Mr. KRAMER. Yes, absolutely. 

Dr. RICH. Sure, yes. 

Dr. FOELS. Yes. 

Mr. DINGELL. I am running out of time, so I am not going to ask 

you to do that at this time, but if you would submit for the record 

some suggestions of what you feel might be useful, I believe it 

would be valuable and helpful to the committee. 

Now, I guess I am going to conclude by pointing out that I think 

that this committee is on the right track. I am hopeful that it will 

continue to have an inclusive bipartisan process that will solve this 

problem which is making a huge mess for all of us, and I think 

that we can no longer kick the can down the road and that now 

is the time for the Congress to act. 

So, Mr. Chairman, I thank you for your work today and for your 

leadership, and I am hopeful that this will lead us towards a better 

conclusion to the situation we confront. And I yield back 27 seconds. Thank you. 

Mr. PITTS. The chair thanks the gentleman and now recognizes 

the chair emeritus of the full committee, Mr. Barton, for 5 minutes 

for questions. 

Mr. BARTON. Thank you, Mr. Chairman. I want to commend you 

and the full committee chairman for starting this process. I think 

this is something that, given good will on both sides, we might actually could do, and if we are able to accomplish it, it will be a significant achievement of the committee. This is something that is 

long overdue. Go back to Chairman Dingell’s chairmanship, my 

chairmanship, Mr. Waxman’s chairmanship, we have fought with 

this and wrestled with it, and because of the expense and the way 

the Budget Act is, when we get down to the lick-log we have always had to back off. So I hope that this time your efforts and Mr. 

Upton’s efforts with Mr. Waxman and others do bear fruit. 

I just have one general question to the panel. It is the issue of 

balanced billing. It is currently prohibited. I am a proponent of 

whatever system we move to, that it should be something to be alVerDate Nov 24 2008 11:36 Dec 03, 2013 Jkt 037690 PO 00000 Frm 00112 Fmt 6633 Sfmt 6633 F:\MY DOCS\HEARINGS 113\113-50 CHRIS
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lowed. It makes sense. It allows physicians, providers to bill for 

those services that are not reimbursable. And I would just like the 

panel’s general position on whether we should include some provision for balanced billing. 

Dr. RICH. So I think balanced billing, it is a touchy topic. I think 

it should be discussed and it should be vetted through the provider 

community as well as your committees. There is a way to sort of 

balance bill already in the Medicare system, and that is just to be 

a nonparticipant, but there are caps on the amount that you can 

balance bill a patient. So it is not very much. It is 105 percent of 

Medicare. And it doesn’t take many patients not to pay their bill 

before it doesn’t work. So balanced billing has been something that 

people have talked about and there likely is value in having discussion and perhaps introducing it into the legislation. 

Ms. DAMBERG. While this is not my particular area of expertise, 

your comments, I think, highlight another deficit around aligning 

incentives across the healthcare system, and that is price transparency. So I think to the extent that you are considering any kind 

of balanced billing provision, I think that that has to go hand in 

hand with full disclosure of prices for patients, because I know on 

various occasions I have gone into the fee-for-service market where 

they no longer take health insurance, and when you ask physicians 

to tell you what the cost of the visit is going to be, they can’t tell 

you that, and they often refuse to tell you that. 

Mr. BARTON. Anybody else wish to comment? 

Dr. FOELS. I would agree with the two previous statements. I 

think, to Dr. Damberg’s point, the ability to capture balanced billing and include that in the efficiency profile of the physician for 

complete transparency would also have to be discussed. 

Mr. BARTON. OK. I yield back, Mr. Chairman. 

Mr. PITTS. The chair thanks the gentleman. 

Now recognize the gentleman from Texas, Mr. Green, for 5 minutes for questions. 

Mr. GREEN. Thank you, Mr. Chairman, for holding the hearing. 

And like all of us, for 16 years now, we have been trying to figure 

out what we are going to do with the SGR, and this is an important step in that effort. I thank our witnesses for being here. 

In the interest of transparency and opportunities for public 

stakeholder engagement are vital to quality measure development 

and approval process. Currently, mechanisms such as the National 

Quality Forum endorsement process that measures application 

partnership input and pre-rulemaking and rulemaking solicit and 

incorporate multistake stakeholder feedback can help. In addition, 

the Secretary of Health and Human Services is in charge of the 

National Quality Strategy, which it is a national overarching strategy to guide quality measurement activities and identify gaps in 

the current framework. 

First, Mr. Kramer, I would like to hear your thoughts on the current state of the quality measurement oversight in the Nation’s 

quality agenda. Do you believe we are on track and what more can 

be done to drive the quality improvement and measurement? 

Mr. KRAMER. Thank you for the question. I will speak on behalf 

of Pacific Business Group on Health, but I am also a member of 

the board of directors of the National Quality Forum as well as NaVerDate Nov 24 2008 11:36 Dec 03, 2013 Jkt 037690 PO 00000 Frm 00113 Fmt 6633 Sfmt 6633 F:\MY DOCS\HEARINGS 113\113-50 CHRIS
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tional Priorities Partnership that measures application partnership, but I will speak on behalf of PBGH. 

I think it is fair to say that the current process is to develop, endorse and prioritize and put into use performance measures, are 

not getting the results we want. I think this opinion is shared fairly broadly by purchasers, patients, providers, and health plans. 

That being said, there are some elements of the current structure 

and process that I think we can build upon. In particular, the National Quality Strategy, I think, represents a robust, well-vetted 

process to develop a clear set of priorities for the Nation. But we 

need to speed up the development of the process of developing and 

using measures at all steps of the pipeline. 

At the front end, measure development, Congress needs to invest 

in the development of patients-centered measures to complement 

the measures that are currently in use. These measures represent 

a public good of enormous value. For a very small investment, the 

payoff, in terms of improved health and health care, is enormous. 

The next step in the pipeline, measure endorsement, we need to 

streamline the process for reviewing proposed measures and getting input from all stakeholders. National Quality Forum has already begun to make improvements in the endorsement process 

through the work of all stakeholders. I hope we can build upon 

that. 

Mr. GREEN. With respect to reforming SGR, in all honesty, if we 

reform the SGR with the goal of making sure we are paying for, 

you know, quality and measurements, I think we will see that 

input. But with respect to reforming it, are there current mechanisms that are both substantive and nimble enough to meet the 

policy framework in the discussion draft of the legislation? Is this 

legislation something that makes that possible? 

Mr. KRAMER. I think this legislation will be a significant stimulus to development of better measures. It needs to be, I would recommend strongly, that it be paired with investment in development 

of quality measures and a clear direction to CMS to ensure that the 

measure endorsement process is streamlined, efficient, and involves 

all stakeholders. 

Mr. GREEN. OK. I only have a minute. 

Mr. Kramer and Dr. Foels, should participation in clinical improvement activities be included as a component of performancebased payment? If so, how could this be structured to support and 

incentivize meaningful quality improvement in a way that is not 

otherwise captured? 

Dr. FOELS. Well, I think that is probably one of the most critical 

areas to address when addressing this issue of quality measurement, is how will it be reported, how will it be actionable, and trying to look for the process by which systems of care can be reengineered to deliver that quality. 

To an earlier comment today, no physician goes in intending each 

morning to deny care to a particular percentage or to do less than 

what is absolutely best, but it is often a system of care that they 

provide in their office or among physicians that functions such that 

that is the byproduct. And so I think we need to continue to think 

about the ability to apply these measures on systems with deep colVerDate Nov 24 2008 11:36 Dec 03, 2013 Jkt 037690 PO 00000 Frm 00114 Fmt 6633 Sfmt 6633 F:\MY DOCS\HEARINGS 113\113-50 CHRIS
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laboration, learning improvement, and share best practice across 

this. 

Mr. GREEN. I only have a couple of seconds, but I want to make 

sure that investing in health information technology, medical home 

certification and use of clinical decision support tools, that could be 

used as part of the performance-based payment, I would hope, because that seems like where we are going. 

Dr. FOELS. Exactly to my point. Clinical decision support would 

be a new system of care delivery that would close those gaps. 

Mr. GREEN. Thank you, Mr. Chairman. 

Mr. PITTS. The chair thanks the gentleman. 

Now recognize gentleman from Illinois, Mr. Shimkus, 5 minutes 

for questions. 

Mr. SHIMKUS. Thank you, Mr. Chairman. 

Real quickly, Mr. Kramer, I am interested in your opening statement, you talked about surgery and checking. Wouldn’t it also have 

been nice to know, be able to search for fees? For fees or the cost. 

Or did you ever, after you went through the whole operation, did 

you know the total cost? 

Mr. KRAMER. Absolutely. You raise an excellent point. I focused 

in my opening comments on the quality measures for the surgery 

I was undergoing, but an essential element for any patient is to 

also know the price. Building on Dr. Damberg’s earlier comments 

about the importance of price transparency, this is one of the areas 

where consumers are looking for information and it is simply not 

available, whether in Medicare or in commercial insurance. 

Mr. SHIMKUS. And I was just going to say, because Dr. Damberg, 

Ph.D. Doctor, not to diminish, but you did mention transparent in 

the answer to one of the questions as being a pretty key component. 

Ms. DAMBERG. That is right. I do think that consumers very 

much want that information, particularly as, you know, insurance 

products change, and even in the Medicare program consumers face 

more and more out-of-pocket expenses. And, you know, having 

them be exposed to more cost-sharing helps align the incentives to 

the consumer about appropriate use of care, but again, that has to 

go hand in hand with transparency on prices so that they can make 

those. 

Mr. SHIMKUS. And I really buy that, especially in the preventive 

care model. If you can really use transparency and you are encouraging people in wellness, you know, however the transparent system is, and encouraging people for generics versus, you know, the 

name brand, I mean, there is a lot of things you can do. But if the 

consumer is not in the game because it is a healthcare debate, then 

you lose all that additional thought process. 

In rural America, there is access issues, and inner-city issues, as 

was highlighted earlier, where Americans will pay for quality, we 

know that, or assumed quality. There are, Dr. Burgess is gone, but 

there are cases of problems in the healthcare system with some 

providers who are not—I mean, in any organization there are some 

problem individuals who disparage and hurt the entire group. And 

my concern would be then erased because of available funding requirements having to have a lesser choice in quality is a concern. 

So there is a need to protect that both, I think, in inner-city regions 

110 

and also the rural care. But I am very interested in this reform 

proposed, and we have section 2 and subsection (h), which talks 

about providers paid under alternative payment models. 

And so the question would be, I would like first to Dr. Foels, understanding the premise of the question, can you tell me how using 

alternative payment models can help fix this system and be beneficial? 

Dr. FOELS. Yes. There are several ways. You know, our firsthand 

experience with our Primary Connection model is to retain fee for 

service where there is the potential for the underutilization of services. So fee-for-service reimbursement is very effective, for example, 

in encouraging preventative care visits, immunizations, and so 

forth. 

The perversity of fee for service is that it recognizes, by and 

large, only face-to-face encounters and only those that occur between a physician or midlevel practitioner, and it doesn’t recognize 

all of the very effective and beneficial work that can be delivered 

by a care team of nurses. It does not recognize telephonic interaction. It does not recognize electronic interaction with patients, 

which can be very effective. So we developed a component of a prepaid allocation to the practices that was not visit dependent or necessarily provider dependent but was tightly adherent to outcomes. 

The third piece here, in savings, really gets back to that earlier 

issue of price transparency, so allowing a primary care physician 

to be rewarded for efforts with their collaborative team of specialists or hospitals to avoid redundancy of testing, to find those components of the system that operate the most efficiently and effectively, and to steer patients in those directions. 

Mr. SHIMKUS. And, Mr. Chairman, just follow up just on that answer. 

Shared savings, what do you mean by shared savings? 

Dr. FOELS. Well, our model of shared savings for primary care is 

upside only, so it does not include any punitive downside, and it 

is measured on the total cost of care for the population, total population of patients assigned to that primary care group, and any incremental savings off a previous year’s budget are shared proportionately back to them. 

So again they are rewarded for the hospitalization that could 

have otherwise been avoided, which is also a quality issue as well 

as a cost-effective issue regarding alternatives. 

Mr. SHIMKUS. OK. Thank you, Mr. Chairman. 

Mr. PITTS. The chair thanks the gentleman. 

And now recognize the gentlelady from Florida, Ms. Castor, 5 

minutes for questions. 

Ms. CASTOR. Well, thank you, Mr. Chairman. I really appreciate 

you calling this hearing today on this important topic. 

And I appreciate the witness testimony very much. You have 

made some very constructive recommendations. And I think the 

general parameters are clear. That is the easy part. We want to 

permanently replace the Medicare physician payment formula, this 

SGR that is very poor public policy, and replace it with a new payment model that improves the quality of care and lowers the cost 

of Medicare. And that is very easy to state, but it is much harder 

to get done. 

111 

But I know that we can do this. Just look at the report from the 

Medicare trustees last week. The reforms that we adopted in the 

Affordable Care Act are helping to reduce the growth in spending 

in Medicare already. Health spending in Medicare is expected to 

grow at a slower rate now than the overall economy in the next 

several years. So that is good news, and it does give us an opportunity to take some of the more difficult steps in payment reform. 

But I have to say, I was very surprised in the Republican discussion draft, because I think we are so far beyond the discussion 

draft. It doesn’t provide us with any real direction on payment reform, and I think that is unfortunate. Unless we change it substantially, the way it is crafted now, it will keep us wedded to the SGR 

and that poor public policy of temporary patches and outdated 

spending patterns. 

I think better model to look to is the bipartisan bill H.R. 574 that 

I am a cosponsor of. It was drafted by Congresswoman Allyson 

Schwartz and Congressman Joe Heck. It is called the Medicare 

Physician Payment Innovation Act of 2013. It provides greater detail. 

And when you compare the two, if you look at the current discussion draft now, I don’t like that it has upfront cuts to providers. 

It doesn’t really provide any innovation in what we need to do. We 

should be incentivizing physicians to transform their practices and 

participate in these innovative payment models. And what this discussion draft does, it says you can opt in if you like. And that is 

why I think it is too squishy.To use a technical term, it is kind of 

wimpy. And we can do a lot better. We have the experts here that 

can help us get there. 

If you look at H.R. 574, it repeals the Sustainable Growth Rate 

permanently, stabilizes the current payment system, it institutes 

interim measures to ensure access to care coordination, it gives 

that important boost to primary care that I think everyone agrees 

on, we can build on the reforms in the Affordable Care Act. And 

then what it does, it says we are going to aggressively test the 

models and evaluate these payment models. It provides a very significant transition period, and as Dr. Rich recommended, the focus 

on best practices and the clinical registry. 

So I would recommend to my colleagues to put out a real discussion draft where we can start to get to the more difficult decisions. 

One of those, what a number of you have mentioned, some of the 

high cost areas. We know we need to boost primary care and align 

doctors and have them work together better, but there are some 

certain high cost areas. You said there are 10 to 12 we should focus 

on. And, Dr. Foels, you said it has been difficult in transition, but 

you have arrived at some interesting payment systems. 

Could you all highlight some of the specific areas, high cost, that 

are going to need greater transition periods or you think we should 

focus on that are crying out for reform? 

Ms. DAMBERG. I think you are asking a broader question than 

just around measurement. So when I was talking about the 10 to 

12, these are clinical specialties that if you look at sort of the majority of care that seniors need, it falls into areas such as cardiology, gastroenterology, endocrinology, neurology. And recognizing 

that, you know, we are in this sort of space where there is a vacuVerDate Nov 24 2008 11:36 Dec 03, 2013 Jkt 037690 PO 00000 Frm 00117 Fmt 6633 Sfmt 6633 F:\MY DOCS\HEARINGS 113\113-50 CHRIS
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um of measures at the moment, and the realistic implementation 

of these programs, I think the idea should be to focus on where 

most of the action is in Medicare and focus the measure development work in that space in the near term. 

So that can be used in any payment model that exists in the 

Medicare program. And one of the comments that is in my longer 

testimony is that whatever happens in the context of the SGR reform should work to align with programs that exist throughout 

Medicare, including the incentive program for meaningful use of 

electronic health records. There is a significant amount of alignment and coordination that can happen there, both as physicians 

and the LNC work with her, electronic health record vendors to ensure that the EHRs have the functionalities to capture the data 

that clinicians need to manage care and to report out these measures and to build in those clinical decision support tools to help 

physicians manage to appropriate care. So those exist in any system and that is something we should be working for across the entire Medicare program. 

Mr. PITTS. Gentlelady’s time has expired. 

The chair recognize the gentleman from Pennsylvania, Dr. Murphy, 5 minutes for questions. 

Mr. MURPHY. Thank you, Mr. Chairman. I just want to make 

sure, and I am particularly focused on the two physicians who are 

here, this basically puts the onus on the academiesand colleges of 

medicine, various subspecialties, upon you to provide quality standards of best clinical practices. Is that the way you read this? OK. 

And also that the specialties then are to develop on the front end 

the standards of protocols for best practices and apply those. Is 

that the way you read this as well? I want to make sure I am understanding this the same as you. 

But I also understand that different specialties are farther advanced than others in terms of really establishing protocols. Am I 

correct on that? Dr. Rich, am I correct on that? 

Dr. RICH. Yes. 

Mr. MURPHY. Now, would you see this, in terms of quality measures, that basically this is a payment model that is based upon 

that if you adhere to the standards and protocols established by the 

medical specialties, that would be considered a quality measure? In 

other words, if they said for this diagnostic workup or for this diagnosis, once these results are in, this treatment plan, this is the protocol you follow and that would be the standard by which payment 

would be attached. 

Is that your understanding, Mr. Rich? 

Dr. RICH. Yes. 

Mr. MURPHY. Now, what happens if a provider feels the need to 

vary from that protocol? Does this bill adequately address that yet 

or do we need some more work in that area? 

Dr. Rich. 

Dr. RICH. So I think, yes. So we work as a specialty society to 

develop on an evidence basis guidelines, and we go out to our membership and say get with the guidelines and here are the guidelines 

for these, you know, procedures that you are doing. So you are absolutely right. 

113 

The bill doesn’t address discretion that physicians have in using 

technologies and drugs that are what we would call off-label use. 

And when I was at CMS, we discussed this at great length, even 

into the Secretary’s office, and the message back to me was that 

we didn’t want to interfere with the discretion of the physicians 

who are taking care of these patients to use a technology or drug 

within a certain patient. It can be abused. And so I don’t think it 

goes far enough here in the legislation. 

Mr. MURPHY. Well, let me ask you this, too, and Dr. Foels, as 

well as you can answer this. Then would it be—I mean, just other 

issues here—that, for example, if a person is board certified in a 

certain specialty, that they—perhaps one of the ways we could 

word this—is that person would be granted a little more latitude. 

So, for example, if you are recommending something as a thoracic 

surgeon, and someone else who is a practitioner, it is not within 

their area but they are following your protocol, that your recommendation, because you are board certified in the area, if you 

are varying from that protocol, might that be some other wording 

we could look at, or whatever that is. I am asking the both of you 

if you have any suggestions, we would appreciate that. 

Dr. FOELS. Well, to comment on the board certification. That has 

evolved significantly in the past decade. Most recertification in a 

medical specialty involves quality assessment improvement efforts 

within your practice, so I think board certification is much more of 

a tangible marker of quality and improvement. 

To your earlier comment about guideline, I would concur with 

Dr. Rich that there are very appropriate times where a guideline 

is not the path that should be taken with a particular patient. The 

frequency with which that occurs has potentially predictable 

ranges, and I think that the guideline adherence can be measured 

within certain degrees based on that. 

Mr. MURPHY. Let me ask this, too. In terms of a payment model, 

I can understand how this could work if you have, for example, a 

hospital-based employee, where you have a large number of physicians and providers, a wide range of specialties practicing, because 

then the hospital could receive or the network could receive a global payment for that patient that covered life. If someone, however, 

is in a private practice, how do you work out the payment systems 

and still have enough incentive for people to work as integrated, 

coordinated care team. I am asking anybody on the panel because 

that is a key question. 

Dr. RICH. So you could do global payments. We did in Virginia, 

we did it in our hospital with independent practices. It is just an 

agreement, a transparent agreement that you can have, and we 

worked on that. 

Mr. MURPHY. Who controls that payment then? I mean—— 

Dr. RICH. So in Virginia, it was the hospital. The payment flowed 

down to the hospital and then they distributed it under agreement 

to the providers, and the providers were selected out depending on 

their quality and their reputation in the community. 

Mr. MURPHY. I am a psychologist by training, and I am on some 

hospital staff, but if a physician refers to me from another hospital 

and I am not part of the hospital staff, how do they work out that 

payment system? And I know I am out of time, but that is someVerDate Nov 24 2008 11:36 Dec 03, 2013 Jkt 037690 PO 00000 Frm 00119 Fmt 6633 Sfmt 6633 F:\MY DOCS\HEARINGS 113\113-50 CHRIS
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thing, I think, we really have to work out in terms of this, how we 

handle. And it does make reference to people who are nonphysician 

providers, but that is something we would appreciate your input 

on. 

Thank you for the time, Mr. Chairman. 

Mr. PITTS. The chair thanks the gentleman. 

Now goes to the gentlelady from California, Mrs. Capps, 5 minutes for questions. 

Mrs. CAPPS. Thank you, Mr. Chairman. 

Thank you all for being here for this important discussion. I have 

long been a supporter of fixing the SGR and am happy we are continuing that conversation. Before I get to my questions, I just want 

to highlight, as we continue on this series of hearings addressing 

the SGR, I want to make sure we do not forget to address other 

items as well, like therapy caps that have historically moved alongside the yearly doc fix and share the common purpose of ensuring 

access to critical care for our Nation’s seniors, and the opportunity 

to finally address the GPCI and other geographic payment inequalities that leave so many providers, especially those in my district, 

unfairly reimbursed and seniors with really fewer options. 

Now, switching gears, as we focus today on quality, I would like 

to take a broad look at our health system. There has been a lot of 

talk in here on this committee about the role of doctors in the 

healthcare system, very appropriate, but as I have said before, I 

truly believe if we are going to really move to a more comprehensive prevention-focused system of care, we need to look at the full 

picture of our healthcare system. This is especially critical when it 

comes to addressing quality. 

Most of the new delivery models like patient-centered medical 

homes and accountable care organizations emphasize team-based 

care, and they recognize the critical role and value of nonphysician 

providers. As such, I think it is important to acknowledge the role 

of other healthcare providers like nurses, nurse practitioners and 

physician’s assistants in this conversation as well. 

So, Dr. Foels, you state in your testimony that management of 

preventive health and chronic disease is inherently team based, 

which I agree. Could you expand on how diverse providers could be 

incorporated into any reformed Medicare payment system and 

what are your thoughts about their role and how they might improve quality and value? 

Dr. FOELS. Well, I can perhaps briefly reflect on my earlier comment on an existing fee-for-service reimbursement system, which 

does not really recognize team-based care to any great degree. A 

large portion of preventive care can be delivered by nurses or advanced practice nurses who can identify missed opportunities for 

preventive services, make those arrangements. This does not require the time of higher licensed individuals. One of our mantra is 

always practicing to the top of your license. 

Mrs. CAPPS. Right. 

Dr. FOELS. And I think it is fairly true that nurses are inhibited 

today, in part by the payment system, from practicing to their full 

extent. 

Mrs. CAPPS. Thank you. I agree. 

115 

And I want to return now to Cheryl Damberg. Under the proposed revision of SGR, which emphasizes best quality practices, 

nonphysician providers paid under the Medicare payment system 

are also expected to be rated on quality measures. 

In your testimony, Dr. Damberg, you highlighted how we must 

enlist providers as true partners in defining the measures for 

which they will be held accountable for as teams and providers. In 

your opinion, do nonphysician providers need unique measurement 

sets compared to physician providers, and what role do you believe 

they should play in defining these measures? 

Ms. DAMBERG. Well, let me start with the latter part of your 

question. Absolutely, they should be involved. And I think with all 

of the changes that going on in health care right now, practices are 

rethinking how they use people. But I want to note that what 

drives measurement is it is patient focused, so the patient’s health 

needs determine what measure gets applied. And so if these other 

nonphysician providers are qualified to deliver that care that the 

patient needs, then those same measures would apply. So it is not 

clear to me that you would develop a set of measures that, say, 

apply to nurse practitioners, but rather the measures are developed 

around the patient and his or her needs. 

Mrs. CAPPS. I see. That is intriguing, and I guess I would have 

to say it is pretty novel. Do you see glitches in or challenges in 

going from the way we do it now to something like this? 

Ms. DAMBERG. I actually don’t think it is inconsistent. If you look 

at the care that, you know, if you go to your physician practice site 

that you hope that they are delivering, you hope that that care is 

appropriate for you, given your gender, your age, and your health 

conditions, right? And the way in which measures are constructed, 

it really reflects that. 

So, you know, if you are a diabetic, they are looking to control 

your blood sugar and your lipid levels, as well as your blood pressure. So I think it is really an issue of, you know, getting the right 

measures that focus on the major clinical issues that face patients 

in our healthcare system. 

And then in the context of constructing those measures, you designate who are the appropriate specialties, and some of those may 

be nonphysicians, who should be held accountable for delivering 

that care. 

Mrs. CAPPS. I see some other people nodding. I know my time is 

up. Is there a general agreement with this? Yes? 

Mr. KRAMER. I would just say that example of good team-based 

care, which involves nonphysicians as well as physicians, is the intensive outpatient care program piloted by Boeing and adopted by 

a number of other large employers for taking care of very sick people with multiple medical conditions. It has been very successful in 

involving all members of the team, working to the top of their license. It has been done in a more affordable way, getting better 

clinical outcomes, better patient experience, better provider experience, and lower costs overall. Be glad to share the additional information. 

Mrs. CAPPS. I would appreciate that if you include that in the 

record. 

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Mr. KRAMER. Yes, it is included in the supplemental materials 

we have submitted to the committee. 

Mrs. CAPPS. Excellent. 

Mr. PITTS. The gentlelady’s time has expired. 

The chair now recognizes the gentleman, Mr. Guthrie, 5 minutes 

for questions. 

Mr. GUTHRIE. Thank you, Mr. Chairman. Thanks for convening 

this. And I agree with our distinguished chairman emeritus, Mr. 

Dingell, working together bicameral, bipartisan, trying to solve an 

issue that whenever we get to the countdown of SGRs in the past, 

that is what I hear about when I go home, is from physicians and 

people in the medical field. And so it is important that we are 

doing this and doing it way early and getting ahead of it before we 

get to that point. So it shows that things are working, and hopefully we can work to get a solution. So I appreciate that very much. 

And to follow from my friend from California was talking about, 

just measurements and qualities, and, you know, a large number 

of the quality measures in use today were developed following scientific processes to ensure their continued importance, scientific acceptability, which is important, usability, feasibility for reporting. 

However, there are many more measures in widespread use that 

fail to meet or require additional resources to meet these criteria 

for national reporting. 

And Dr. Damberg, what process or processes could be enacted 

that would ensure quality measures or measurement sets are developed with high scientific rigor, maintain currency to the latest 

evidence-based clinical practices, and are relevant to new care delivery systems? 

Ms. DAMBERG. So if CMS were taking the lead on measure development, I think what they have to do is institute a process where 

they work with measure developers who understand the scientific 

requirements and steps in a measure development process, which 

includes reviewing the evidence, holding panels with clinical experts that can include physicians and nonphysicians, to ensure that 

the underlying science is right, and then working to develop a draft 

measure specification that you go out and test and validate. 

So they need to set up a rigorous transparent process to do this. 

And I think that it should involve clinical subspecialists and primary care physicians in identifying what those performance gaps 

are. And if you go out and you talk to physicians, they know where 

the gaps in care are, and so I think by linking the clinical specialists with the performance measure developers, I think you can 

have a robust development system that will create confidence in 

the system. 

Mr. GUTHRIE. Well, thanks. And I am also on the Telecom Subcommittee of this great committee, and we are dealing with trying 

to update things, and telecom is changing so fast, where there is 

a system that doesn’t happen. 

So I guess also ask, in health care, my lifetime, they have gone 

from 6 weeks of recovery from gallbladder surgery to outpatient 

care. So just as those things, as we innovate and develop, the system has to be there and develop with that. 

117 

Ms. DAMBERG. Yes, the system has to be nimble enough and 

there have to be resources available to allow for annual re-review 

of measures and updating as necessary and retiring as necessary. 

Mr. GUTHRIE. Well, thank you. 

And, Dr. Foels, how would these processes ensure that quality 

measures evolve with data accumulation and advancement in 

measure development science and appropriately account for the relative value of measures as they relate to other measures and use? 

I think I just used measures as every part of speech. 

Dr. FOELS. Well, you know, I actually want to build off Dr. 

Damberg’s comments in that regard and at the same time address 

the issues you have raised. 

So there are a couple of layers deeper that also have to be fully 

explored, examined and monitored, and one has to do with the 

methodology for attribution and accountability. I think the other 

take-forward lesson we have learned from our community is that, 

although various metrics are—certain of them are very attractive 

because of their ease of operational measurement, aren’t terribly 

important because the community is already achieving reasonably 

high rates of success. And so prioritizing the measures to which are 

most important and impactful is also going to be, I think, a critical 

byproduct of whatever group is assigned this task. 

Mr. GUTHRIE. Well, it is amazing how innovative we are in medicine, you know, from cancer drugs to where it killed all cells to get 

the cancer cells to where they are trying to—in Louisville, University of Louisville, is a doctor there pioneering going to individual, 

where they actually get just the cancer cells, as you all know better 

than I. I just want to make sure that whatever system we have, 

innovation and processes that allow innovation and keep up as we 

change are in place. So I appreciate that very much, and I yield 

back 10 seconds. 

Mr. PITTS. The chair thanks the gentleman. 

Now recognize the gentlelady from Illinois, Ms. Schakowsky, for 

5 minutes for questions. 

Ms. SCHAKOWSKY. Thank you, Mr. Chairman. 

I have some questions for you, Dr. Damberg. Optometrists, podiatrists, optometrists, chiropractors have all been recognized by 

Congress within the definition of physician providers in the Medicare statute. Those medical providers follow the same rules and 

policies as other physician providers who deliver high quality services to the Medicare population. 

For example, these providers face the same threat of reimbursement cuts under the SGR as M.D.s or D.O.s. Using the same rules 

for all providers included within the physician definition allows 

Medicare patients the freedom to choose among licensed healthcare 

providers for covered services. 

I have concerns that the discussion draft actually would undermine a patient’s access to the provider of their choice by allowing 

the Secretary to establish separate quality update incentive programs for optometrists, podiatrists, chiropractors than those established for M.D.s and D.O.s, and it seems to me this could result in 

providers who perform the same services being assessed by different quality standards and receiving different payment adjustments. 

118 

So let me ask you if you think it is important for every physician 

provider treating the same problem to be measured using the same 

quality measurement system and eligible for the same quality update incentives? 

Ms. DAMBERG. I actually do. I think, again, per my earlier remarks, the clinical care that is delivered should be focused on the 

patient’s needs, and whatever provider is addressing those needs 

should be held accountable. And I recognize that there are variations across health systems in how they deploy personnel. So I 

know firsthand, when I had my bunion surgery at Kaiser, I had a 

podiatrist who was involved in that. So, again, I think it is very 

important that the same set of measures apply as relevant. 

Ms. SCHAKOWSKY. So talking about the patient, by having different quality measures and incentives, do you think that that 

could affect their access to quality care and their choices? 

Ms. DAMBERG. Do I think it could affect Medicare beneficiaries? 

Ms. SCHAKOWSKY. Yes, different, if we had different quality 

measures, might it not affect them? 

Ms. DAMBERG. It is not clear to me that it would necessarily affect access to care. I mean, I think potentially the risk around access more generally in any incentive-based program comes when 

incentives get so large that they distort behavior, and particularly 

in the context of outcome measures you have not accounted for underlying patient factors that attribute to the outcome such that 

physicians or other types of practitioners may choose to avoid treating patients. 

Ms. SCHAKOWSKY. OK. And currently, don’t optometrists, podiatrists, chiropractors follow the same criteria right now and successfully report the same quality measures as M.D.s and D.O.s? 

Ms. DAMBERG. In the measurement programs that I have been 

involved with, I have not seen evidence that they are reporting 

those measures. So I don’t have any knowledge of that firsthand. 

Ms. SCHAKOWSKY. OK. Another quality initiative being implemented in Medicare is the electronic health record incentive program, which provides incentive payments, as you know, to physician providers as they adopt, implement, upgrade, demonstrate 

meaningful use of the her technology. Do you know if optometrists, 

podiatrists and chiropractors are included in this program? 

Ms. DAMBERG. I do not know that. 

Ms. SCHAKOWSKY. OK. And let me see if—I think these all deal 

with those. You may not know the answer to this. The answer is 

yes, actually. Like these quality initiatives, isn’t it important for 

the quality update incentive program being proposed for Medicare 

to require all physician providers in the Medicare program, including those other providers I listed, to use the same standards and 

receive the same incentives for the same services? I think it is another way of asking the same question. 

Ms. DAMBERG. The answer should be yes, they should be held accountable to the same standards. I would be loathe to set up two 

different incentive systems. I just think the complexity of it and 

sort of the challenge is in sending very different signals. If anything, what we want to be doing is be creating greater alignment 

across physicians, other practitioners in the ambulatory care setting as well as aligning incentives across the system in which the 

119 

patient travels. So aligning incentives between physicians and hospitals, that is so very critical. And again, the extent to which this 

bill can help push that ball down the field a bit more would be very 

helpful. 

Ms. SCHAKOWSKY. Mr. Chairman, I just want to say how much 

I appreciate the tone of this hearing and this discussion, and I hope 

we could have more like it. Thank you very much. 

Mr. PITTS. The chair thanks the gentlelady. 

Now recognize the gentleman from Virginia, Mr. Griffith, 5 minutes for questions. 

Mr. GRIFFITH. Thank you very much, Mr. Chairman. 

I appreciate all of you being here today, and I know there is 

some good questions that you already answered, and I am going to 

yield the rest of my time to Dr. Burgess for additional good questions. 

Mr. BURGESS. And I thank the gentleman for yielding. 

Mr. Kramer, let me just ask you a question. In your testimony, 

you talked about incentives and providing—building incentives into 

the structure, but oftentimes, here in the people’s House, we end 

up talking about making something punitive rather than providing 

an incentive. Can you speak to that and the differential between 

those two activities, building in an incentive versus building in a 

punitive activity? 

Mr. KRAMER. I will offer my opinions on this, although maybe it 

is best answered by a psychologist. But I think that my experience 

and experience of our members at PBGH is that positive incentives 

for doing the right thing are very powerful. There are occasions, 

however, we want to put in place a mechanism to avoid bad things, 

and it may be that in some situations that some kind of penalty 

would be appropriate. 

For example, we want to avoid infections, you know, high rates 

of infection, we want to avoid high rates of mortality, we want to 

avoid high rates of unnecessary hospital readmissions. There may 

be some situations like that in which a penalty would be appropriate, but I think in most cases they can be restructured as a positive incentive. So the negative side of infections is infections are too 

high, therefore reward progress on reducing infections and frame 

it as a positive incentive, I think that could be most effective in 

moving us in a direction so that we get the results we want. 

Mr. BURGESS. You know, my old epidemiology instructor from 

Southwestern Medical School used to tell me that in order to adequately measure something you had to eliminate fear, and the providers must not be in fear; otherwise, they are not going to be as 

forthcoming with you when they have problems. And that is one of 

the difficulties I see in constructing a system that is more punitive 

than one based on incentives. So I agree with you, and certainly 

the prescription drug or the providing for electronic e-prescribing, 

it wasn’t part of the healthcare law, it was part of the stimulus bill, 

you are actually going to build some resentment toward e-prescribing because of the fact that it is a reimbursement reduction if 

that doesn’t happen, rather than building in an incentive. And I 

hope we can be sensitive and careful about that as we construct 

this. 

120 

Dr. Foels, I just want to continue our discussion on the fee-forservice aspect for a moment where we kind of got cut off by time, 

but I do feel so strongly that in our reform of the SGR, you have 

to allow the—I mean, a lot of physicians of my age group, fee for 

service is what we have always known. We are goal directed. It is 

an incentive to which we respond. And to just start out with the 

premise that we are going to eliminate all fee-for-service practice 

in many ways I fear will only harden those people who would be 

resistant to the new payment models. And I would just encourage 

us, as we think about this, there has to be a place for the fee-forservice physician in the new Medicare model, in the new SGR, 

whatever is the follow-on from the SGR. I always use the example 

of Muleshoe, Texas, literally a one-stoplight town with one GP, and 

it is hard for him to be an ACO. I mean, I guess he can call himself 

ACO, but it is hard for him to be an ACO because he is just a country doc working in a little town and he gets paid for his services. 

I think you have to allow him the ability to continue to practice. 

Do you disagree with that? 

Dr. FOELS. I agree with your point. I think, again, there are systems of care that are all various levels of maturity and depths of 

integration across the country. Many of them will be willing to accept a more advanced payment system early on. Others—— 

Mr. BURGESS. And I agree with you, but it should be their choice. 

It should be their choice when they go into that system. And if the 

guy in Muleshoe can’t do it, we can’t exclude him because he is all 

they have got, correct? 

Dr. FOELS. And to your earlier point, too, about the accommodation of physicians to a new system of payment, we have probably 

over a century of experience in the United States with a fee-forservice system, so it is something that everyone is extremely accustomed to and our systems of payment are all operationally designed 

around it. And we even found, in our own experience, despite our 

deep collaboration with our primary care community, that they 

were not immediately willing to transition to a new care model 

until we profiled them under how they would actually perform 

under that and we made the methodology completely transparent. 

But that took an additional year or two for them to be willfully accepting of the change. 

Mr. BURGESS. So that is an educational endeavor. 

Thank you, Mr. Chairman. 

Mr. PITTS. The chair thanks the gentleman. 

Now recognize the gentlelady from North Carolina, Mrs. Ellmers, 

for 5 minutes for questions. 

Mrs. ELLMERS. Thank you, Mr. Chairman. I appreciate so much 

the opportunity to be participating in this subcommittee hearing on 

SGR reform. I think that it is something that is vital to healthcare 

reform into the future. 

And I thank our panel for being here and giving your input as 

well. I certainly associate myself with many of your comments on 

best practices, Dr. Damberg, especially when we are talking about 

making improvements with science-based, real information that 

will actually improve our healthcare system. 

That brings me, Dr. Kramer, to one of the other discussions that 

was just taking place. We were talking about whether there is 

121 

room or should there be room for penalties, essentially, I will call 

it that. And one of my big concerns is that many times physicians 

are placed in a position because there is a new best practice that 

is established, may or may not be science based, but Medicare will 

require that they adhere to that, and it may end up in a bad patient outcome, an increase in infection rate or something else. 

In your words, how would you address that? How can we avoid 

that situation happening where a physician possibly may be penalized or cannot participate in an incentive program because there is 

some best practice that is put in place? How could we address that? 

Mr. KRAMER. I would answer by saying that if we keep the focus 

on the patient, and the results, the outcome, the clinical outcomes 

to the patient and the patient’s experience in those outcomes, that 

will address many of the underlying problems that currently exist. 

So, for example, rather than focussing on whether a clinical best 

practice was followed or a clinical guideline was followed, rigid adherence to that can sometimes lead to bad results, the inappropriate results. 

Mrs. ELLMERS. Yes. 

Mr. KRAMER. So rather than focussing on rigid adherence to the 

clinical practice guideline—— 

Mrs. ELLMERS. It should be patient centered. Patient outcome. 

Mr. KRAMER. Patient centered. What happened to the patient? 

Was that best for the patient? Did it get the right results? That is 

what physicians are working toward, that is what drives them as 

individuals, and that is what we ought to be rewarding. 

Mrs. ELLMERS. Thank you. I appreciate you saying that. That is 

my opinion as well. 

Dr. Damberg, in the draft of our legislation that is definitely ongoing, we are going to be taking in so much more feedback to make 

sure that what we put in place is an actual working model that will 

work in the real world and not just in theory. In your testimony, 

you talk about the collaboration between CMS and establishing a 

process where measures can be developed between clinical specialists and correcting that performance gap area. In your opinion, how 

important is this relationship between CMS and medical providers 

in maintaining that value-based performance? 

Ms. DAMBERG. So I think for this program to be successful CMS 

and the physicians have to work in a very close partnership, and 

that partnership starts with the measure development process, but 

it extends way beyond that to CMS trying to figure out how to support physicians regardless of what type of practice they are in, but 

I would say especially focused on the kinds of practice that Mr. 

Burgess was talking about, which are, you know, the smallish practices that may be miles away—— 

Mrs. ELLMERS. Right. 

Ms. DAMBERG [continuing]. From big centers where they can 

work with other partners to develop capacity. I think that there is 

a lot of work that needs to go on, on the ground, to develop capacity 

in practices so that they can achieve the results that we want them 

to. And there are various entities in communities across this country who are already working with providers. 

And I think that CMS should look to leverage those partnerships 

with community players, and I also think that CMS should look 

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very carefully at private commercial health plans who are also investing substantial resources to work with community providers 

and build capacity. And I think if they could align the deployment 

of those improvement resources and work in partnership, that 

would be a huge help to providers. And I think there are lots of 

incentives in place for that to happen because many of the commercial health plans participate in Medicare Advantage and are at risk 

financially for a quality bonus payment themselves. 

Mrs. ELLMERS. Thank you. I appreciate your comments. 

And I see that I have run out of time. Thank you, Mr. Chairman. 

Mr. PITTS. The chair thanks the gentlelady. 

Now recognize the gentleman from Florida, Mr. Bilirakis, for 5 

minutes. 

Mr. BILIRAKIS. Thank you, Mr. Chairman, I appreciate it. And I 

thank the panel for their testimony. I have a couple of questions. 

Start with Dr. Damberg. You talk about a continuum of performance. Should we target a percentage for performance of quality 

measures? For example, should the average physicians meet 75 

percent or 85 percent of performance measures? If the averages are 

above the targeted percentage, should we recalibrate the metrics 

every 5 years or so to adjust the metrics and increase the standard 

of care? 

Ms. DAMBERG. So you are talking about where to set these performance thresholds? 

Mr. BILIRAKIS. Sure. 

Ms. DAMBERG. Yes. So there are several different ways in which 

you can establish benchmarks. One is to use national performance 

benchmarks that are already in place. If you look at the National 

Committee for Quality Assurance, they have many benchmarks already for ambulatory care measures. 

But there are more sophisticated methods. I would call your attention to my testimony where I reference a report by a statistician 

named William Rogers and Dana Safran at Blue Cross Blue Shield 

of Massachusetts, and I am not going to go mathy on you, but they 

used the beta-binomial distribution to set this. And in essence, 

where they set the top threshold tends to remain very stable over 

time, and it sets up sort of the optimal performance that can be 

delivered safely. Because I know one of the previous questions was 

around, you know, are we going to not give physicians some flexibility around the care they provide? I don’t think we personally 

want to drive everybody to 100 percent, because I think there are 

some reasons why patients should not get care. 

Mr. BILIRAKIS. All right, thank you very much. 

This is for the entire panel. Do you support quality measures tailored to specific diseases such as diabetes and Parkinson’s? And if 

so, how do you develop quality measures for rare diseases? These 

are hard to diagnose diseases with small populations. If we do develop metrics for specific diseases or conditions, how do we responsibly develop measures for these conditions when research may be 

somewhat limited? Whoever would like to address it first. 

Mr. KRAMER. We do need to develop better measures for disease 

conditions, both common conditions, unfortunately common conditions, such as diabetes, as well as rare conditions. I think a number 

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veloped and through the endorsement process. I think the National 

Quality Forum has done a reasonably good job of bringing together 

clinicians, patients, patient-advocate groups, as well as other stakeholders to find the best measures, encourage measure developers to 

put those forward, and to build on what is already there so that 

those measures are in place and are available and the outcome results are available to clinicians for their clinical quality improvement efforts, to teams, who are often in a very good situation to 

manage the care for someone with chronic conditions, but also to 

patients so that they can identify the best providers and participate 

in their care. 

Mr. BILIRAKIS. Anyone else? 

Dr. RICH. Definitely should have measures for disease conditions. 

So when I was at CMS in 2008 we did an analysis of the three biggest cost buckets for Medicare populations, and depending on what 

decile of Medicare patient you were looking at, it was always congestive heart failure, coronary artery disease, and cancer. And you 

could reverse the order depending on how old the patient was. But 

that represented somewhere around 45 to 47 percent of the 

healthcare dollar that we spent at Medicare. And if you are going 

to create disease-specific measures you should start there, and I 

think that would be what Mrs. Castor would want to hear as well. 

I do think that there is a team approach to taking care of people 

with coronary artery disease. Myself, a cardiologist, PCP, all care 

for these patients, the same for heart failure, and creating a robust 

set of measures for a disease-specific entity like that across specialties and cross into primary care. 

Ms. DAMBERG. May I add one more point? 

Mr. BILIRAKIS. Yes, please. 

Ms. DAMBERG. I think that the other thing that I would keep in 

mind is, right now we have some one-off measures, so in the area 

of diabetes. I would encourage development of measures with an 

entire episode of care. So if you think of hip replacement surgery, 

you know, you may start in the ambulatory setting, you transition 

into the hospital and then you may end up in post-acute care. And 

so we need to look at this larger bundle of measures that hang together to cut across that continuum. 

Mr. BILIRAKIS. Anyone else, does anyone disagree with the disease-related measures, or specific measures? 

Dr. FOELS. If I could just reiterate a point that was made earlier, 

that a particular quality measure does cross disciplines. It follows 

the patient. And we have had some recent experience with applying diabetic measures to cardiologists who are also caring for those 

patients, and we know diabetes is a strong risk factor for coronary 

disease. 

And it is important that the cardiologists are also a participant 

in improving diabetes care as well. It may not be an area to which 

they feel they should naturally be measured, but we feel as an integral part of an entire team that cares for that particular chronic 

condition, it would be appropriate to apply measures in that regard. 

Mr. BILIRAKIS. I have one more question, Mr. Chairman. 

Mr. PITTS. Go ahead. 

124 

Mr. BILIRAKIS. Just briefly. What about patients? Should patients groups have a role or input into the process when determining these measures? 

Mr. KRAMER. Absolutely, yes. Patients is why we are here. We 

are here to take care of people who are beneficiaries of Medicare. 

And more broadly, if it is done right for Medicare, can help our entire healthcare system. By keeping a patient focus, finding out 

what is important to them in terms of their outcomes, making sure 

we have measures of those outcomes, and then providing rewards 

to physicians and care teams to achieve those outcomes, that will 

do what is right for the patient. If it is done right for the patients, 

it will work for the rest of us. 

Mr. BILIRAKIS. Thank you, Mr. Chairman, I yield back. 

Mr. PITTS. The chair thanks the gentleman. 

Now recognize the gentleman from Louisiana, Dr. Cassidy, 5 

minutes for questions. 

Mr. CASSIDY. Thank you, Mr. Chairman. 

First, Dr. Rich, I will just say that there is a T-surgeon, Gene 

Berry, that first acquainted me with your data set on quality. Very 

impressed with it. I just thought about it ever since. So let me compliment your society and my local doc who acquainted me with 

that. 

Mr. Kramer, I enjoyed your remarks. If you are the guy that 

broke your face playing basketball, I got to tell you, man, your hair 

is a little gray to be up there on the court. But that said, you know. 

Listen, we do have to be patient focused. 

Now, I will say that solutions in Washington tend to be big. Affordable care organizations are huge. And as a doc who is thinking 

that oftentimes you are going to have a four- or five-person practice 

in which, unless you figure out how to align the patient with the 

interest of that four- or five-person practice, you are not really 

going to serve those patients best. 

Then, Dr. Foels, I was impressed that your organization seems 

to have been somewhat entrepreneurial adapting. My thinking is 

that we need something, we call it in this legislation an alternative 

payment model, where you take that entrepreneurial group of docs, 

whoever they might be, and you allow them to come up with a different model that none of us have thought about, but in their circumstances works for their patients and for their practice better 

than anything else, and that CMS, frankly, would be required to 

approve unless they could show why they should not, as long as the 

folks doing the model were willing to take the risk. Any thoughts 

on that? 

Dr. FOELS. Yes, I would concur. Our participation with other like 

plans, regional, not-for-profit insurers that also have deeply collaborative efforts with the community, are moving toward—and we 

do that work through the Alliance of Community Health Plans and 

share a lot of excellent work across disciplines. But what we have 

found, although we work toward a common goal, we have taken different approaches, and many of those approaches have all been 

equally successful. 

Mr. CASSIDY. Yes. 

Dr. FOELS. But there are significant and slight differences among 

them that we need to recognize are regional. 

125 

Mr. CASSIDY. I totally get that. If your final outcome is giving access to high-quality medicine at an affordable cost, there may be 

different goals depending upon the practice and upon the patients. 

So, one, compliments you all for doing so. And, two, I hope this legislation enshrines that. 

Dr. Damberg, one thing—I could have asked this of many of 

you—one thing that has been occurring to me though, I am liver 

doctor who takes of cirrhotics, I am always struck that primary 

care doesn’t want to touch that cirrhotic once they have cirrhosis 

because it is such a fragile patient. So what do you think, I have 

tried to coin a phrase called, not primary care physician, but principal care physician. If you take someone like a nephrologist caring 

for the renal failure patient, she is really the principal care physician even though she is not, quote, the ‘‘primary care physician.’’ 

Cancer doctors. Patients with heart failure. And really trying to 

align a payment model to recognize that once someone has CHF no 

one touches that patient unless the cardiologist first blesses the 

touching. Does that make sense? I see Dr. Rich nodding his head. 

Do you all have any thoughts on this principal care concept? Dr. 

Damberg, I started it with you. 

Ms. DAMBERG. So let me ask you a question back. 

Mr. CASSIDY. Yes. 

Ms. DAMBERG. Are you considering this person—hopefully this is 

not too much of a value-laden term—almost like a gatekeeper for 

that person’s care in terms of coordinating the management? 

Mr. CASSIDY. The principal care physician would then take on 

the responsibilities currently ascribed to the primary care. It just 

recognizes that if somebody has cirrhosis—— 

Ms. DAMBERG. Something very complex. 

Mr. CASSIDY [continuing]. They become the one who becomes the 

coordinator, they become the hub off which everyone else radiates. 

Ms. DAMBERG. Yes. No, I actually think there is potentially some 

value in that. I think we are looking to primary care, and particularly medical homes, to coordinate a lot of care, but there may be 

care that is sort of outside the purview of primary care where I 

think it could be useful to set up someone who would be—— 

Mr. CASSIDY. I think if you look at Medical Advantage’s special 

needs programs, most of those folks are probably not managed by 

primary care in an urban setting. They are managed by some gal, 

some guy who happens to be a specialist in their condition. 

Mr. Kramer, from the business perspective any thoughts you 

have? 

Mr. KRAMER. Yes, I think this makes sense. I think a term that 

we actually use, informally, is accountable care physician. I think 

it gets at the same thing. There is a physician that may be a specialist, may be a primary care physician, but for certain kinds of 

patients it would make sense for the specialist to be the accountable physician for the care that is delivered to that patient working 

with his or her team. 

Mr. CASSIDY. So if there was a payment model in which—an alternative payment model in which a group of gastroenterologists 

would take on the risk bearing of a group of cirrhotics pre-transplant patients, they would then become the accountable physician, 

if you will, at risk, and then coordinating the care, being the priVerDate Nov 24 2008 11:36 Dec 03, 2013 Jkt 037690 PO 00000 Frm 00131 Fmt 6633 Sfmt 6633 F:\MY DOCS\HEARINGS 113\113-50 CHRIS
126 

mary care doc for a group of fragile patients. You all are nodding 

your head yes. 

Mr. KRAMER. And rewarded for the quality and the total resources used on behalf of those patients. 

Mr. CASSIDY. Yes. Well, thank you for your input. 

I yield back, Mr. Chairman. 

Mr. PITTS. The chair thanks the gentleman. 

Dr. Christensen has a unanimous consent request. 

Mrs. CHRISTENSEN. Thank you, Mr. Chairman. Yes, I ask unanimous consent to insert into the hearing record a paper from the 

National Senior Citizens Law Center and a letter from AFSCME, 

both on balanced billing. 

Mr. PITTS. Without objection, so ordered. 

[The information appears at the conclusion of the record.] 

Mrs. CHRISTENSEN. Thank you. 

Mr. PITTS. All right, that completes our first round. We will do 

one follow-up per side. 

Dr. Burgess, 5 minutes for follow-up. 

Mr. BURGESS. Thank you, Mr. Chairman. 

Dr. Damberg, let me just ask you, can you discuss at all to the 

extent that providers are dealing with measure reporting, quality 

improvements, and financial arrangements to link quality payment, is this something that is ongoing that you have observed? 

Ms. DAMBERG. So, yes, indeed. I would say the majority of physicians, at least in primary care in this country, have ongoing measurement reporting of some sort and payment tied to performance. 

In the clinical specialty areas, it tends to be tied to, again, the set 

of measures that have been identified, whether that is care for diabetes or cardiac-type measures. In some cases those physicians’ 

payments are also tied to performance currently. 

Mr. BURGESS. Just specifically in the primary care world, so 

those measures have already been developed. Are we going to—— 

Ms. DAMBERG. They have been developed. They are in widespread use. Many of the pay-for-performance programs in the private sector have actually been in operation since about 2003. So it 

is a long period of time. 

Mr. BURGESS. But do you think it is possibly to integrate them 

into whatever happens in the Medicare world? 

Ms. DAMBERG. Absolutely, and I think the CMS should be looking to align the measures. So the ambulatory physicians are already accountable through their health plans for the Medicare Advantage measures. Those measures represent a really strong starting point, and that you are basically not asking those physicians 

to do something different. 

Mr. BURGESS. Why do you suspect that there has not been wider 

involvement of that or wider institutionalization of that? 

Ms. DAMBERG. Of the fee-for-service side of Medicare? 

Mr. BURGESS. Well, on the Medicare Advantage side where it 

does seem like you have got happy providers, you have got happy 

patients, the cost is less. Why is there not wider adoption of that 

within the Medicare system itself? Because there does seem to be 

some resistance to the Medicare Advantage model. 

Ms. DAMBERG. Well, I think if you look at the physician valuebased payment modifier program, that is essentially trying to move 

127 

down that path with physicians across the board within Medicare. 

So even absent the SGR, that work is in process. And again, I 

think it is going to be the primary care physicians who are first out 

of the gate on that because of the existence of measures. 

Mr. BURGESS. Yes, in many ways, if the SGR could not be reformed, if we didn’t have the favorable CBO score winds at our 

back, it has always seemed to me that Medicare Advantage may 

offer a way forward on whatever happens with SGR down the road. 

Is that a fair observation? 

Ms. DAMBERG. I think possibly. I do think Medicare Advantage 

has been a leader, and it is not surprising because much of the 

measure, the performance measurement work that has gone on historically has been on the managed care side even in the commercial 

sector. But even private payers recognized they were not getting 

value out of the providers on the fee-for-service side, and so they 

shifted those programs into play in fee for service. 

Mr. BURGESS. Very well. Let me just ask a question, generally, 

and anyone can feel free to answer or not. But should the quality 

improvements undertaken by a physician or a practice, should the 

quality improvements themselves be included as a component of 

whatever performance-based payment is adopted? If you have a 

doctor who realizes that at the start of the year they are not performing as well as they might, and improves their performance, 

can that be taken into account, the fact that they have improved 

their performance? 

Dr. RICH. Yes, absolutely, I think. And if you look at the hospital 

value-based purchasing program, it is written into that. So you can 

have targets, we can have absolute targets, or you can have a quality improvement incentive. So you can’t take a low performer and 

expect them to get to 90th percentile in 1 year, so you ought to be 

able to reward them to go from the 10th to the 30th percentile as 

an incentive to keep trying. 

Mr. BURGESS. And just as a practical matter, you think that is 

something that should be included in whatever follows on from 

SGR? 

Dr. RICH. Yes, absolutely. 

Mr. BURGESS. Mr. Chairman, I shouldn’t do this, but I actually 

want to recognize Dr. John O’Shea, who is here in the audience. 

He has had a big hand in helping us get to where we are today, 

and we were sorry to lose him, but at the same time, we are grateful to have had the association in the past couple of years where 

he has been so instrumental in getting this tough problem moved 

along. So I will yield back my time. 

Mr. PITTS. The chair completely agrees with that statement. 

Thank you very much. 

The chair recognizes Dr. Christensen for 5 minutes for a followup. 

Mrs. CHRISTENSEN. Thank you, Mr. Chairman, and I don’t think 

I will take all of 5 minutes. But this is a little bit of a different 

question. But we have not been able to fix malpractice, do malpractice reform. And I wonder if the panelists think that the reforms that we are talking about, and comparative effectiveness research and some of the other provisions could lower the risk of lawsuits and perhaps even the cost of liability insurance? 

128 

Dr. RICH. I do. I think if you get providers to participate in clinical registries and quality improvement programs, I think that 

would be recognized, not only by insurance companies to lower your 

cost, but just in general I think it would help the healthcare system to reduce complications and reduce lawsuits. 

Mrs. CHRISTENSEN. OK. Well, a lot of what we are talking about 

in terms of reform relies a lot on primary care physicians. Do you 

have any concerns that we are not producing enough family physicians, or primary care physicians, or do you think we are on target 

for where we need to be with primary care physicians? And if not, 

what do we do until we get there? 

Dr. FOELS. If I may comment, I have very deep concerns about 

the adequacy of the primary care physician workforce. When, 

again, one steps back and thinks about a viable, vital primary care 

team, it takes the discussion to a little different level above and beyond recruiting interested residents in a primary care professional 

track. I think there is considerable work that has yet to be realized 

in making this an attractive specialty. 

I think the reengineering of primary care alone, and the ease of 

work through efficient systems of care that will evolve, which I 

hope will evolve over very short periods of time in primary care, 

will again make this a very attractive discipline. And to my early 

earlier comment, I think we are still underutilizing the valuable 

talents of nursing staff to provide care, and a reform payment system would be a valuable contribution toward moving in that direction of, again, designing a viable, vital primary care team. 

Mrs. CHRISTENSEN. Thank you. 

Anyone else? 

Ms. DAMBERG. I also share that concern, and I think one of the 

issues that hasn’t been addressed here, but I know is being talked 

about is reweighting the payments such that, you know, if we are 

going to talk about incentives, right now I think the incentives in 

the system in terms of the payment structure really go against 

going into primary care as a specialty. So I think we need to look 

at ways to correct some of those imbalances in payments. 

Mrs. CHRISTENSEN. Thank you. 

Mr. Chairman, I don’t have any other questions, so I will yield 

back my time. 

Mr. PITTS. All right. Chair thanks the gentlelady. 

That completes our questioning. I am sure some members will 

have additional questions. We will submit those to you in writing. 

We ask that you please respond promptly. 

And as I stated in the opening statement, we are seeking substantive feedback on ways to complete this legislative draft. I 

would encourage all interested parties to submit their comments to 

the committee by next week. 

I remind the members, they have 10 business days to submit 

questions for the record, so they should submit their questions by 

the close of business, Wednesday, June 19th. 

Without objection, the subcommittee is adjourned. 

[Whereupon, at 12:17 p.m., the subcommittee was adjourned.] 

[Material submitted for inclusion in the record follows:] 

129 

PREPARED STATEMENT OF HON. RALPH M. HALL

Mr. Chairman, I would like to commend you for all the hard work that you have 

done, including the coordination with the Ways and Means Committee, to bring us 

to this point where we can have a meaningful hearing on the Sustainable Growth 

Rate issue. This is a complex issue, and the stakeholders are many, but it is an 

issue that we must resolve before the end of the year. 

As we move forward in this process, we are going to need to resolve not just the 

important details of the ‘‘doc fix’’ issue, but also the need for spending offsets to assure that the legislation does not have a significant impact on our budget. In that 

regard, I would like to suggest one budget savings that might be included as an offset in this bill. It is the language of H.R.1076, which is legislation that I have introduced along with Mr. Olson and others. Our bill would assist political subdivision 

health care pools by giving employees in these pools the same premium tax credits 

and cost sharing assistance that will be available in the new health care exchanges. 

But the employees in these health care pools would only get the assistance on one 

condition—if they can show that doing so would save the federal government money. 

Most states have one or more of these health care pools. In Texas, we have one 

for small towns and one for county employees. In our case, the health care plans 

offered in these pools are expected to be less expensive that those that will be available in the exchanges. So keeping these employees where they are—in less expensive plans that provide the same quality of coverage—means that the value of the 

tax credit will be less, and the impact on the federal budget will be less. 

Mr. Brady, who Chairs the Ways and Means Health Subcommittee, has asked 

CBO for a score of this language. When we get that score and find out how much 

budget savings the language will generate, I hope we can consider including it in 

this bill as an offset. 

I look forward to working closely with the Chairman on this idea. 

PREPARED STATEMENT OF HON. HENRY A. WAXMAN

I would like to thank the Chairman for holding this hearing. Today’s discussion 

will focus on some of the critical questions the Committee must address as we look 

to finally solve the problem of the broken Medicare Sustainable Growth Rate formula which has been plaguing Medicare for too long. 

It’s clear from this and others hearings we’ve held on the topic that there is broad 

consensus on the need to fix this problem, and even consensus on which direction 

we need to move and the broader policy goals that will get us there. The question 

is how to get there, and, like all things, the devil is in the details. 

The Affordable Care Act provided a good foundation and charted the right path 

forward. Through its support for new delivery and payment models like accountable 

care organizations, bundled payments, medical homes, and initiatives that boost primary care—it moves us in the direction of improved quality, efficiency, and value. 

I am pleased that the Chairman has reached out to us to try to move forward 

in a bipartisan fashion. Our discussions so far have been largely fruitful. The earlystage, draft legislative language released by the Chairmen adheres to these shared 

policy goals on which we’ve reached broad agreement. 

However, thoughtfully crafting legislative language that effectuates these goals is 

a challenge—one that we are doggedly attacking in collaboration. All policies have 

consequences, some are apparent and some are unforeseen (as we’ve painfully witnessed with SGR). And this is precisely why this hearing is important, but also why 

we need to continue to refine, vet and develop the concepts that will move us from 

a volume based system to a value based system of physician payments. 

With that in mind, there are three key challenges that I’m interested in hearing 

about today: (1) Recognizing that fee for service medicine will remain a part of our 

health system, how do we best deal with incentives that drive volume at the expense of value; (2) How do we get physicians to accelerate the move to new delivery 

system models that can improve care without compromising cost; and (3) How do 

we make sure we don’t throw the baby out with the bathwater—for example, CMS 

has been working to build a solid array of quality measurement programs, and has 

been working to develop new models—we don’t want to be starting from scratch. 

I am glad to see the Chairman continuing to move forward on this issue early 

in this Congress, and we look forward to continuing to refine these policies through 

a bi-partisan approach. 

130 

PREPARED STATEMENT OF HON. FRANK PALLONE, JR. 

Thank you Chairman Pitts. I commend you for your continued commitment to addressing Medicare’s flawed sustainable growth rate (SGR) payment model. Over the 

past few weeks, our staff have come together and had meaningful conversations on 

this topic. While I have not signed on to the discussion draft before us today, I can 

assure you that the Democratic staff are still working to find a permanent fix to 

the SGR, and look forward to continuing to work with the Republican staff to do 

so. 

As I have said before, fixing the SGR system is one of my top priorities. For too 

long, Congress has passed short-term fixes to override arbitrary cuts to physician 

payments generated by the SGR formula. It is not fair for physicians or their beneficiaries to continually be faced with uncertainty, and these short-term fixes are not 

financially sustainable. It is time for us to come together in a bipartisan manner 

to repeal and replace the SGR formula. 

We can all agree that the current SGR system is unstable, unreliable, and unfair. 

I also believe that, broadly, we all have the same goals for what an SGR fix will 

look like. However, getting these goals into legislative language is a complicated 

task. With so many moving parts, it is critical that we fully understand the consequences of each provision and gather views from all stakeholders. This is not a 

process that should be rushed. Let’s work together to make sure we get this right. 

A new payment model should focus less on volume of services provided, and instead rely upon improved outcomes, quality, safety, and efficiency. By focusing on 

these goals, we can improve patient experience and reduce the growth in health care 

spending simultaneously. While there may still be a need for a fee-for-service option 

within the future payment system, a new system must better encourage coordinated 

care while incentivizing prevention and wellness within the patient. 

The Affordable Care Act established a number of new provider arrangements 

under Medicare, such as new Accountable Care Organizations (ACOs), which encourage cooperation and coordination among providers, hospitals, and suppliers, so 

that patients receive high-quality, efficient, and cost-effective care. As we work to 

replace the SGR, we should look to these programs as a starting point for developing a payment model that moves away from traditional fee-for-service and toward 

a system that focuses on quality and outcomes. 

I look forward to hearing from our witnesses today about their perspectives on 

the best way to prioritize quality and address the flawed SGR, and I look forward 

to continuing to work with my colleagues and all stakeholders to finally find a permanent fix. 

Thank you. 

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85440.082

National Senior Citizens Law Center 

Balance Billing Prohibition-A Crucial Protection 

The prohibition against balancing billing is a crucial protection. Without it, low income 

Medicare beneficiaries will be cut off from access to their Medicare benefit 

Individuals who receive Medicare and Medicaid services, known as dual eligibles, 

cannot afford Medicare's 20% co-pay for services. Dual eligibles are universally 

acknowledged to be an extremely vulnerable and medically fragile group. 85% of have 

incomes below 150% of the federal poverty line.' In general, the Medicare program 

covers 80% of Medicare approved charges, and Medicare beneficiaries are required to 

pay the remaining 20% of the Medicare-approved fee-for-the service.2 Because 

Medicaid payment rates are very low and state Medicaid programs are only required to 

make copayments up to the Medicaid rate, Medicaid usually fails to pay the difference.3 

With balance billing protections, these individuals maintain access to the 

Medicare benefits that tbey or their spouse has earned. They can continue to see 

Medicare prOViders knowing that they will not be subject to bills they cannot pay and 

ultimately collection proceedings. Without balance billing protection, dual eligible 

individuals are afraid to see Medicare providers and amass medical debt that they 

cannot pay. 

Balance billing is a bedrock protection. Witbout it, a low income Medicare 

beneficiary is effectively cut off from access to their Medicare benefit. 

The balance billing protection as currently defined is inadequate because many 

Medicare providers still are unwilling to accept patients without full Medicare 

reimbursement. One positive development is the Section 1202 Affordable Care Act 

provision that sets Medicaid rates for primary care at the same level as Medicare.' The 

provision is important as it has the effect of giving primary care providers who serve 

dual eligibles the full Medicare payment. But that ACA provision sunsets in two years 

and only applies to primary care. A better long-term fix is needed to ensure continued 

access to needed care. Until then, the balance billing prohibition is a crucial protection. 

1 Jacobson, G., Neuman T., & Damico, A" (April 2012). Medicare's Role for Dual Eligible Individuals~ Kaiser 

Family Faundation Medicare Policy, 2, Retrieved from www.kff.org/medicaidjupload/2186_06.pdf. 

2 Center for Medicare Advocacy, Medicare Part B. Retrieved from 

http://www.medicareadvocacy.org!medicare-info!medicare-part-b. 

:1 Burke, G., & Prindiville, K., (November 2011). Improving the Qualified Medicare Benefit Program For Dual 

Eligibles, National Senior Citizens Law Center, 6. Retrieved from www.nscic.org/wpcontent!uploads/2011/11!lmproving-QMB-for-Duals-Brief.pdf . 

.4 Public law 111-152, "Health Care and Education Reconciliation Act of 2010." 

1 
132 


85440.083

Alliance of Specialty Medicine 

Testimony for the Record 

Before the House Energy and Commerce Committee 

Subcommittee on Health 

Hearing Entitled 

"Reforming SGR: Prioritizing Quality in a Modernized Physician Payment System" 

Wednesday, June 5, 2013 

Chainnan Pitts, Ranking Member Pallone, members of the Committee, and honored guests, the Alliance 

of Specialty Medicine (the Alliance) would like to thank the House Energy and Commerce Committee 

for the opportunity to provide feedback on its May 28, 2013 draft legislation. The Alliance strongly 

supports your intent to repeal Medicare's sustainable growth rate (SGR) fonnula and to replace it with a 

payment system that places greater emphasis on quality and efficiency. The Alliance is a coalition of 

medical specialty societies representing more than 100,000 physicians and surgeons dedicated to the 

development of sound federal healthcare policy that fosters patient access to the highest quality specialty 

care. 

Our written testimony will not only detail some outstanding questions and concerns regarding the Fee 

Schedule Provider Competency Update Incentive Program, which the Committee proposes as Phase 2 of 

its Medicare payment refonn proposal, but also briefly outline our suggestions and principles for SGR 

reform. We would be happy to discuss our concerns and principles with you, as well as any other 

questions you may have going forward. 

The Alliance again thanks the Committee for the opportunity to provide feedback and looks forward to 

working with you to refine this legislation and work toward a permanent and meaningful solution to the 

flawed physician payment system. 

Many of the Alliance's specialty society member organizations currently have, or are in the process of 

developing, physician-driven quality improvement initiatives, including the development of clinicallyrelevant perfonnance measures based on evidence-based guidelines, the management of clinical data 

registries and enhanced maintenance of certification (MOC) programs. While more work remains, these 

physician-driven initiatives often result in a more accurate snapshot of specialty care and produce more 

relevant feedback to specialty physicians than current federal initiatives, which lack sufficient flexibility 

to accommodate different specialties and care settings, rely on measures that are inadequately risk 

adjusted and not necessarily linked to better patient outcomes, and divert significant resources away 

from direct patient care due to administrative complexities. 

Taking these experiences into account, the Alliance appreciates the opportunity to share with the 

Committee the following outstanding questions and to offer potential solutions regarding the Fee 

Schedule Provider Competency Update Incentive Program, which the Committee proposes as Phase 2 of 

its Medicare payment refonn proposal: 

The manner in which the update adjustment would take into account quality assessments is a 

significant issue that remains undefined. It is critical that the Committee claritY this point and 
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85440.084

then seek public feedback on its recommendation. Quality programs must rely on positive incentives 

rather than penalties to encourage participation and trust in the system and to ensure that physicians 

can continue to invest in quality improvement infrastructure and provide patients with the access to 

care that they deserve. Physicians should not have to start out from a negative and then have to 

"claw" their way back up to a payment rate that still may not even cover the cost of practice. 

The manner in which the base payment will be determined and updated is another critical 

issue that is undefined. The Alliance supports the use of the Medicare Economic Index (MEl), 

which is more predictable than the SGR or other mechanisms, and more accurately captures the true 

costs of providing physician services. 

Any system that replaces the SGR should incentivize participation in quality programs rather 

than reward or punish physicians based on flawed ranking systems. Publicly available rankings 

provide little value in terms of educating the public or promoting quality care unless they reflect 

substantial and verifiable differences in quality. Unfortunately, the methodologies to accurately 

make these assessments remain flawed. Much work still needs to be done to ensure risk adjustment 

and attribution methods are fair, statistically valid, result in unambiguous comparisons, and do not 

lead to cherry picking of less risky patients or otherwise impede patient access to care. As such, we 

urge the Committee to instead consider a system that recognizes and rewards continuous quality 

improvement rather than one that pits physicians against each another. Evidence demonstrates that 

quality is improved when physicians are provided confidential feedback in a non-punitive 

environment. For educational and improvement purposes, confidential feedback reports may include 

information regarding how a particular physician or physician group compares to national or 

regional benchmarks, however, we strongly oppose head-to-head comparisons. Additionally, the 

methods used to make any comparisons must be transparent and clearly described. 

The Alliance strongly believes that, if updates are to be based on quality evaluated through a 

newly proposed structure, existing programs and associated penalties need to be repealed and 

replaced with programs that more accurately and meaningfully reflect the care provided by a 

range of physician practice types as provided by the respective societies. Our current 

understanding of the May 28th language suggests that the competency updates would piggyback on 

existing federal quality programs, such as the Physician Quality Reporting System (PQRS) and 

Electronic Health Record (EHR) Incentive Program. In particular, language giving the Secretary the 

authority to "coordinate the selection of quality measures ... with existing measures and requirements, 

such as the development of the Physician Compare Website" and "with measures in use under other 

provisions of section 1848" leads us to believe that existing programs would remain in place and that 

the competency update would create additional responsibilities for physicians that could further 

erode patient-centered care. The Alliance has serious concerns about expanding upon what are 

already administratively burdensome programs that rely on metrics of questionable value and 

include future penalties that, when combined, could reduce physician'S payments by almost ten 

percent. Similarly, in the section discussing methods for assessing performance, the Secretary is 

given the authority to incorporate methods from comparable physician quality incentive programs. 

This is concerning because the methods employed under current programs are seriously flawed, have 

undergone little testing, and often result in inaccurate assessments, which breeds frustration and 

mistrust among physicians. As such, we urge the Committee to include language to ensure that 

the PQRS, ERR Incentive Program, and the Physician Value-Based Payment Modifier (VBM) 
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Program are repealed and replaced by any new SGR replacement programs incorporating 

physician quality. 

• The proposed quality measure development process remains vague. While we are pleased that 

the quality measure development process would rely on best clinical practices, and that the Secretary 

may consider measures developed by medial specialty organizations, there is little detail about the 

standards that measure developers would be held to when translating evidence into measures of 

accountability. Current standards, such as those used by the National Quality Forum (NQF), are 

often too resource intensive to justifY specialty society investment, too lengthy to allow for timely 

implementation, and too rigorous to accommodate the testing of more innovative approaches to 

quality improvement, such as reporting to a clinical data registry. We encourage the Committee to 

preserve specific current minimum standards -- such as transparency, minimum sample sizes, basic 

auditing and data integrity/validation criteria, and ongoing evaluations of the effectiveness and 

feasibility of measures -- without being overly prescriptive and limiting the development of more 

innovative measures or approaches to quality improvement. 

At the same time, there is no need to reinvent the wheel and waste resources. In cases where a 

specialty has already invested in the NQF process and NQF-endorsed measures already exist, those 

measures should be used to the extent that they are supported by the relevant medical specialty 

society. 

We also question who would meet the definition of "other relevant stakeholders" eligible to develop 

measures. Measure development must be led by relevant clinical experts, who are most familiar 

with the clinical literature and best equipped to decide on the most appropriate strategies for treating 

specific diagnoses, procedures, and patient popUlations. While multi-disciplinary input is important, 

it is critical that this process be driven only by clinicians with relevant clinical and topical 

knowledge. 

The language requiring the Secretary to select a "sufficient numher" of quality measures for 

potential inclusion in each peer cohort is vague and inadequately reflects measure intensity 

and relevance. In terms of the provisional core measure set, it is unclear how the Secretary will 

ensure that each peer cohort is being held to a similar level of accountability in terms of range of 

measures, measure complexity, and reporting burden. While there is language giving the Secretary 

authority to assign different scoring weights based on the type or category of quality measure, this 

seems to relate more to the calculation of the composite score for individual physicians within a peer 

cohort rather than differences between measure sets across peer cohorts. For example, a single 

measure evaluating whether a specialist reported regularly to a clinical outcomes registry may 

require heavy investments in data collection tools and the collection of more numerous and more 

robust data points, including outcomes, than individual process of care measures which often require 

little more than the checking of a box to indicate that things such as smoking cessation counseling 

were offered. Therefore, we urge you to adopt mechanisms to ensure that all peer cohorts are held 

to a similar level of accountability even if their measures differ in number, type or focus. 

• The requirement to develop core competencies appears unnecessary and duplicative of current 

requirements of the certifying hoards. We do not fully understand the rationale for including yet 

another layer of unnecessary regulatory requirements. The medical profession already fulfills a 

3 
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85440.086

series ofrequirements aimed at ensuring compliance with various core competencies. This starts 

during a physician's medical residency training, with the requirements set forth by the Accreditation 

Council for Graduate Medical Education (ACGME) and the individual specialty Residency Review 

Committees (RRCs), and continues with initial board certification and maintenance of certification, 

pursuant to the requirements of the American Board of Medical Specialties (ABMS) boards. We 

believe that the process for developing meaningful quality measures and other quality improvement 

programs can move forward without creating the additional process of defining core competency 

categories. 

The timeline for solicitation of public quality measure input remains undefined. We urge you 

to legislatively require that the public comment period related to quality measures be open for at 

least 90 days and that the final response include a discussion regarding all of the comments received, 

similar to the current regulatory process, 

The timeline for finalizing measure sets remains undefined. Measures should be finalized at least 

one year before the first day of a performance period. Similarly, the Secretary should provide 

confidential feedback reports to physicians, including new fee schedule providers, for at least one 

year before holding them accountable for performance. 

It is unclear how the Secretary will ensure widespread publication of core measure sets in 

specialty-appropriate peer-reviewed journals should a journal refuse to publish such 

information. Most peer-reviewed journals have independent editorial processes and medical 

organizations, therefore, have no control over what gets published in these journals. Thus, we urge 

you to define alternative mechanisms that may be used to ensure that physicians who will be held 

accountable by these core measures are appropriately informed of the programmatic requirements, 

The Secretary and local Medicare carriers should be responsible for providing this basic information, 

Certainly, the specialty society members of the Alliance are also willing to use our available 

communication tools to educate physicians about applicable quality measures, processes and 

programs that would qualify for the quality portion oftheir payment. 

In addition to the specific questions outlined above regarding the May 28th proposal, the Alliance 

believes that the following elements are critical to any physician payment reform proposal and urges the 

Committee to embrace the following principles: 

Repeal of the SGR, followed by a minimum 5-year period of stability in Medicare physician 

payment; 

Positive financial incentives for higher quality care rather than penalties and withholds; 

Physician-led quality improvement that allows the medical profession and medical specialties to 

determine the most appropriate and clinically relevant quality improvement metrics and 

strategies for use in future quality initiatives; 

Flexible criteria that allow physician participation and engagement in delivery and payment 

models that are meaningful to their practices and patient populations, including FFS; 

Legal protections for physicians who follow clinical practice guidelines and quality improvement 

program requirements; 

Repeal of the Independent Payment Advisory Board (IPAB); and, 

Allowing for voluntary private contracting between physicians and Medicare beneficiaries, 

4 
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85440.087

Finally, in the attached appendix, the Alliance has outlined the extent to which a majority of its member 

organizations are engaged in quality improvement activities, including participation in national multistakeholder coalitions; engagement in public and private payer quality recognition programs; and the 

development of quality measures, health information technology (HIT) products, and clinical data 

registries. 

Thank you again for taking into consideration our written comments. 

5 
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85440.088

Sound Policy: Quality Care 

The Alliance of Specialty Medicine, a coalition of 13 national medical specialty societies representing approximately 

100,000 physicians and surgeons, appreciates the opportunity to provide Members of Congress and their staff with a 

snapshot of specialty society quality improvement activities. Specialty societies are engaged in a variety of efforts to 

improve both quality and efficiency in health care and have developed robust infrastructures to support specialist 

engagement in those activities. Through this work, specialty medicine has found that there is no ~/one-size-fits-all" 

approach to raising the bar on quality and that the optimal model will depend on the clinical context. As such, the 

Alliance firmly believes that the long-term potential to close the gap on quality and achieve better value in health care 

lies in the ability to accommodate multiple aligned quality improvement strategies. We urge Congress and public and 

private payers to support flexible approaches to quality improvement, which recognize activities that are clinically 

relevant to specific physician practices and meaningful to individual patients, rather than any singular approach. 

Below we outline the extent to which a majority of Alliance member organizations are engaged in quality improvement 

activities, including participation in national multi-stakeholder coalitions; engagement in public and private payer quality 

recognition programs; and the development of quality measures, health information technology (HIT) products, and 

clinical data registries . 

• :. Exploring the development of a clinical data registry 

.:. Few quality measures are available for AAFPRS members in existing quality programs 

.:. Implemented an educational portal to facilitate lifelong learning, including CME tracking, MOC and clinical 

research 

.:. Established the National Neurosurgical Quality Outcomes DatabaSe(~;~OD) .:. Engaged in enhanced MOC activities 

.:. Regularly produce, review and endorse evidence-based clinical practice gUidelines 

.:. Developed the Self-Assessment in Neurological Surgery (SANS) 

.:. Participates in the ACR Appropriateness Criteria program for diagnostic imaging 

.:. Promoting development of episode-of-care payments for two common neurosurgical conditions 

.:. Several quality measures are available for neurosurgeons in existing quality programs, but they are not 

meaningful indicators of quality 

.:. Exploring opportunities to collaborate with EHR vendors 

.:. Members of the NQF, AMA PCP I, SQA, and PEHRC 

.:. Exploring the development of a clinical data registry 

.:. Collaborated on the development of Appropriate Use Criteria (AUq for Mohs Surgery 

.:. Few quality measures are available for ACMS members in existing quality programs 

.:. Members of the NQF and AMA PCPI 

.:. Launched the AGA Digestive Health Outcomes Registry, which is integrated into gGastrov4, a certified EHR 

technology 

.:. Developed Practice Improvement Modules (PIMs) for Procedural Sedation/Patient Safety, which is now included 

as part of the ABIM Approved Quality Improvement (AQ!) Pathway 

.:. Launched the Bridges to Excellence IBD Care Recognition program through the Health Care Incentives 

Improvement Institute (HCI3) 
138 


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.:. Participating in the ABIM Foundation's Choosing Wisely Campaign 

.:. Developed a bundled payment mode! for screening colonoscopy 

.:. Several quality measures are available for AANS(CNS members in existing quality programs 

.:. Members 01 the NQF, AMA PCPI, AUA Alliance, and PEHRC 

.:. Participating in the development of a clinical data registry with the American Academy of Ophthalmology and 

other ophthalmic organizations 

.:. Established the Integrated Eye Care Delivery Model, which serves as a medical "eye care" home 

.:. Many quality measures, including outcomes measures for all of the major eye care conditions, are available for 

ACSRS members in existing quality programs 

.:. Members olthe AMA PCP I and IHE Eye Care 

.:. Exploring the development of a clinical data registry 

.:. Developed Appropriate Use Criteria {AUCL in collaboration with other imaging medical societies and 

subspecialty societies, for a variety of imaging modalities effort to guide physicians in determining a rational, 

quality approach to the use of diagnostic imaging 

.:. Participating in the Image Gently Campaign 

.:. Participating in the ABIM Foundation's Choosing Wisely Campaign 

.:. Several quality measures are available for ASE members in existing quality programs 

.:. Members olthe AMA PCPI, IHE Cardiology and DICDM 

.:. Launched the Tracking Operations and Outcomes lor Plastic Surgeons (TOPS) clinical data registry, and a PQRS 

Registry with CECity 

.:. Engaged in MOC activities 

.:. Collaborated with EHR vendors on HIT solutions for plastic surgeons 

.:. Several quality measures are available for ASPS members in existing quality programs 

.:. Members olthe AMA PCPI and SUA 

.:. Launched a PQRS Registry with CECity and developing a clinical data registry 

.:. Participating in the AMA's NQRN and the National Registry Coalition 

.:. Participating in the ABIM's Choosing Wisely Campaign 

.:. Several quality measures are available for AUA members in existing quality programs 

.:. Exploring opportunities to collaborate with EHR vendors 

.:. Members 01 the NQF, AMA PCPI, SUA and PEHRC 

.:. Developing a clinical data registry 

.:. Participation in the ABIM's Choosing Wisely Campaign 

.:. Development of clinical guidelines and appropriateness criteria for spine 

.:. Several quality measures are available for NASS members in eXisting quality programs 

.:. Members olthe AMA PCPI 

.:. SCAI members participate in the NCDR clinical data registry 

.:. Engaged in MOC activities 

.:. Several quality measures are available for SCAI members in existing quality programs 

.:. Members olthe NQF and IHE Cardiology 

Page 2 
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85440.090

ABIM - American Board of Internal Medicine 

AMA PCPI- American Medical Association Physician Consortium for Performance Improvement 

OICOM - Digita! Imaging and Communications in Medicine 

EHR - Electronic Health Records 

HIT - Health Information Technology 

IHE -Integrating the Healthcare Enterprise 

MOC - Maintenance of Certification 

NQF - National Quality Forum 

AMA NQRN - American Medical Association National Quality Registry Network 

PEHRC - Physician EHR Coalition 

SQA - Surgical Quality Alliance 

Page 3 
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85440.091

Dr. Chl'l) I L. Dambcrg 

Senior Poliev Reseorcher and PrOiC$$Of 

Pardee R;\~~D Gradnate School 

]776 Main Street 

Santa Monica, CA 9040!~3'208 

Dear Dr. Dam berg: 

June 26. 2013 

Thank you fcw appearing hefon.~ the SUbCl'1mmiUee on Hcnlth on Wcdncsda~y, June 5. 2013, to 

testify' at the bearing cntitled "Rcft")rming SGR; Prioritizing Quality in 3 :vlodcrnilGd Phys.ician Payment 

SystL'n1.·· 

Pursuant to the Rules oftllc Committee on Energy and Commerco, the hearing rec",mi remains 

open lor ten busincss days to permit [y'1cmbcrs to submit additional questions for the record. which arc 

tllltlched, The format o1'yool' rcspons-cs to these questions should be as folJmvs: (1) the name orthc 

~1ernber whust?' question you are addressing. (2) the comph:..'tc text of the question you are addressing in 

hold. and (3) your answer to that (juestion in plain text, 

Also attached are !\kmbcr requests made during the hearing, The format of your rc-~pol1ses to 

these requests should n)lIow the stunt! f()ffnat as ,Your responsl..:-$ to the additional ques.tions fix the record. 

To t:'lcilitatc the printing of the hearing record, please respond (0 these questions. and requests by 

the close of business on Friday~ July 12t 2013. Your responses should he mailed to Sydne I1ar\\'ick, 

Legislative Clerk. Committee on Energy and Ct1mmcrcC"t 2125 Rayhunl House Office BuildiHg., 

\Vn~hjngton, D.C. 20515 and c-lllailed in \Vord fDlmut to Snlnc.Harwick(iimaiLhousc.gov. 

Thank you ngnin for your time anJ l'rn .. 1rt preparing und delivering testimony bcf\>rc the 

Subcommittee. 

cc: The I Ionorable Frank Pallone . .If., Ranking i'dembcr, Subcommittee on Ilcalth 

l\ttaclul1cnls 
141 


85440.092

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142 


85440.093

Testimony 

Physician Payment Reform 

Designing a Performance-based Incentive Program 

Addendum 

Cheryl L. Damberg 

RAND Office of External Affairs 

CT-389f1 

July 2013 

Document submitted on July 12, 2013 as an addendum to testimony presented before the House Energy and Commerce 

Committee, Subcommittee on Health on June 5, 2013 

This product is part of the RAND Corporation testimony series. RAND testimonies record testimony presented by RAND associates 

to federal, state, or local legislative committees; govemment-appointed commissions and panels; and private review and oversight 

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its research clients and sponsors. RANO® is a registered trademark. 
143 


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85440.095

Cheryl L. Damberg' 

The RAND Corporation 

Physician Payment Reform: 

Designing a Performance-based Incentive Program 

Addendum' 

Before the Committee on Energy and Commerce 

Subcommittee on Health 

House of Representatives 

July 12. 2013 

The subsequent questions and answers found in this document were received from the Committee for 

additional information following the hearing on June 5, 2013 and were submitted for the record. 

The Honorable Joseph R. Pitts: 

1. In your testimony. you state that "value-based payment programs seek to incentivize 

providers to innovate and redesign care delivery to drive improvements in quality and how 

resources are used (i.e. costs)". Do you believe that payment reforms like those 

envisioned in the committee legislative framework hold the potential to improve the quality 

and value of the Medicare program for seniors? 

Since the committee's framework has specifics yet to be filled in, it is difficult to accurately predict what 

the effects would be. The ability to improve quality and value in the Medicare program is contingent on 

the value-based payment program design, which will affect how physicians and the organizations in which 

they work respond. So yes, I believe that with the appropriate design, incentivizing physicians to deliver 

the right care will help to improve the quality and value of the Medicare program for seniors. The design 

of the program is critical in encouraging providers to innovate and redesign care delivery. For example, in 

the context of the emerging Accountable Care Organizations (ACOs), the providers (physicians and 

hospitals) in the ACOs are collaborating and working across their individual care-setting silos on care 

redesign to ensure they hit the cost and quality targets for which they are now jointly accountable. The 

joint accountability is a key design feature. In this case, incentives are aligned across the system to 

ensure that providers are working to achieve the same goalS-better quality and better value for the 

patient and the payer. This is a sea change from what has historically been occurring in the delivery of 

1 The opinions and conclusions expressed in this testimony are the author's alone and should not be interpreted as 

representing those of RAND or any of the sponsors of its research. This product is part of the RAND Corporation 

testimony series. RAND testimonies record testimony presented by RAND associates to federal, state, or local 

legislative commitlees; government-appointed commissions and panels; and private review and oversight bodies. 

The RAND Corporation is a nonprofit research organization providing objective analysis and effective solutions that 

address the challenges faCing the public and private sectors around the world. RAND's publications do not 

necessarily refiect the opinions of its research clients and sponsors. 

2 This testimony is available for free download at http://www.rand.org/pubs/testimonies/CT389z1.html. 
145 


85440.096

health care, where heretofore each physician and hospital has been working independently without 

regard to the actions of others, often resulting in duplication of services with little or no value to patients 

and patients falling through the cracks as they transition between providers and health care settings. 

These have cost and quality implications for patients, and for the government as the payer of care. In the 

context of SGR reform, holding physicians accountable for their performance can lead to improvements in 

care and overall value. Ensuring that the measures for which providers are financially accountable are 

evidence-based (so that providers agree they are important because studies show taking the action leads 

to benefit for the patient) or focus on important patient outcomes can lead to improvements in the 

reliability of the care patients receive and the outcomes they experience. In a recent Expert Panel on 

value-based purchasing (comprised of providers, payers and researchers) that I conducted for the 

Assistant Secretary for Planning and Evaluation in the U.S. Department of Health and Human Services, 

there was consensus among the experts that we should hold physicians and hospitals accountable for the 

outcomes we seek and that if we do, the providers would determine what actions to take (through 

innovation, coordination with health and social service community providers, and care redesign) to work 

towards achieving those outcomes, as multiple factors besides selected processes of care may influence 

them. Outcome measures should include both clinical and cost (measures of overuse of services) 

dimensions; including costs as part of what is measured and how providers are paid is critical to ensure 

that services are efficiently delivered. Physicians who make decisions about treatments have a central 

role to play in helping to ensure that health care remains affordable for patients and other entities 

(employers, government agencies) that pay for care. 

While my comments focused on embedding performance-based incentives into the existing FFS payment 

model as part of the SGR reform, I would underscore for the subcommittee that more wholesale payment 

reform is required to move us beyond the current payment structure that incentivizes physicians to do 

more, often with little to no clinical benefit or that may even harm the patient. Transitioning physicians to 

performance-based pay (in lieu of the SGR) is the first step in a larger journey towards restructuring the 

underlying incentives in health care in order to deliver value. The incentive structures I discussed at the 

subcommittee's hearing on June 5 work at the margin rather than on the base payment. While physicians 

over the next 3-5 years gain greater comfort with measurement and incentives within the FFS structure, I 

would encourage Congress to support CMS and local communities to conduct more wholesale payment 

reform innovations across the United States. allowing payers, physicians. and other stakeholders in 

communities to innovate to advance the delivery of high value health care. Experiments such as the Blue 

Cross Blue Shield of Massachusetts Alternative Quality Contract, which sets a global. payment for care 

and provides performance-based incentives. represent an important step in this direction. 

2. Your testimony outlines the need for "meaningful" payments to help drive value-based 

payments. You also mention that incentives on the order of 5 or 10% would be needed to 

2 
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85440.097

drive meaningful improvement in the system. However, right now the financing of the 

Medicare program is weak and I don't envision that Congress could pass a 10% increase 

for providers (or even a 5% increase) during these times. Are there other ways to structure 

incentive payments without having to rely on a 5 or 10% bonus to providers for practicing 

quality care? 

The implementation of value-based purchasing programs in the United States has emphasized budget 

neutrality, unlike the implementation of pay for performance in the United Kingdom, which involved new 

money on top of a raise for primary care physicians. In the context of no new money, this means that the 

funding for incentives would come from withholds-either from existing payments or from envisioned 

updates to payment-or from savings. In the private sector over the past decade, payers held back a 

portion of anticipated payment updates (e.g., if the year-te-year increase was to be 4%, then 2% would be 

guaranteed and the other 2% would be held back and paid out based on performance) and over time 

accrued more money at risk. Increasingly private payers are moving towards shared savings approaches 

to funding the incentive pool, with providers first needing to hit quality targets and then if they hit cost 

targets, they receive a portion of the savings (typically 50% of the savings). 

3. You state that many primary care providers have already been exposed to the kinds of 

performance measures outlined in the draft legislative framework. In your opinion, are the 

types of programs enVisioned in the committee's legislative framework achievable goals 

for the Medicare program and providers? Also, do you believe they are goals that will 

improve the lives of seniors and taxpayers? 

Private sector and Medicaid plans have been experimenting with pay for performance for much of the 

past decade, and most of the measures in those programs focus on primary care. Because physicians 

typically see a mix of patients from different payers, the concept of pay for performance is not new to 

primary care physicians. The subcommittee has outlined a general framework that I believe builds an 

important path forward for moving providers towards accountability for quality (and hopefully cost)--for 

both primary care and subspecialists. I do believe the framework sets out achievable goals for Medicare 

and providers, and that these will benefit seniors and the taxpayers. A central piece of the work over the 

next five years is the development of measures for each specialty that address important performance 

gap areas and that target areas that benefit patients in terms of their health and functioning. Additionally, 

addressing areas where care is delivered with little or no value will help seniors-who are exposed to 

therapies that may actually harm them-and will help ensure the viability of the Medicare program, which 

must focus on controlling health spending. 

3 
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4. While primary care and some specialty groups have a long standing history of measure 

development and performance, others unfortunately lag behind. Do you believe that all 

provider groups adopting a system of quality measurement will be good for the provision 

of care in this country, and do you believe that provider specialties which are advanced in 

these areas might be able to help those who lag behind? 

There are many clinical sub specialties that have not developed performance measures, while some have 

made significant progress (Oncology, Cardiology, Cardiac Surgery, and Orthopedics). Without doubt, the 

sub-specianies that have made advancements in measure development, measurement and reporting 

through clinical registries, and that make use of that information for quality improvement, can be a 

resource for the specialties that lag in these areas. 

Measure development efforts by the American Medical Association's Physician Consortium on 

Performance Improvement (PCPI) could be a foundation to support development of measures for those 

subspecialties that are currently lacking measures. Also, the recent efforts by the American Board of 

Internal Medicine Foundation (ABIMF), in partnership with clinical specialty societies, to generate 

recommended areas to reduce the overuse of services provides another opportunity that could be 

leveraged to support subspecialists in the transition.' 

I would note that the current process of measure development being deployed through the Medicare 

program requires modification to support the work envisioned by the proposed legislation. As I have 

stated, it will be critical to pull physician leaders together from a particular specialty to identify areas of 

evidence-based practice and areas where performance gaps exist, and to pair them with measure 

developers who can work in concert with the clinicians to develop robust, valid measures. 

5. Your testimony touches on an important point. It is not whether we measure per se but 

really how meaningful the measure is and what it is measuring. In a system like that 

envisioned by the draft legislative framework, how do you believe Congress and CMS 

should ensure that measure development and application are meaningful both now and in 

the future? 

For measures to be meaningful, they must be based on scientific evidence that taking the action (e.g., 

providing beta blockers for those who have had a heart attack) will lead to better patient outcomes (i.e., 

lower mortality). We should not be asking physicians to provide care that has no clinical benefit to the 

patient. Similarly, we should hold physicians accountable for providing care that has little/no benefit (e.g., 

3 Choosing Wisely: an initiative of the ABIM Foundation. 2012 [updated 2012; cited 2012 October 29th, 2012]; 

Available from: http://choosingwisely.org/. 

4 
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per the Choosing Wisely and other specialty reoommended areas related to overuse of health care 

services that are low value). So, CMS should first require that the measures it selects for focus are 

evidence-based. Secondly, CMS should move toward measuring outcomes that both physicians and 

patients agree are important and that can be influenced by the actions of the health care system. The 

value of outcome measures is that they transcend time; they are important now and will be in the future. 

As such, they will require less modification than process measures, which are tied to clinical evidence that 

can change year to year given medical advancements. For measurement of outcomes to be meaningful 

to physicians, it must account for differences in the sickness level of patients across different physicians. 

Otherwise, physicians will have incentive to remove sicker patients from their panel of patients in order to 

perform well on the measures. Third, the development of measures needs to occur using a scientifically 

rigorous process that is transparent, inclusive of physicians and other stakeholders, and ensures the 

reliability and validity of measures that become the basis of payment. Measure development is a science. 

It requires careful review of the scientific evidence to identify areas that define high quality care (which 

form the measure ooncept), vetting the evidence and ooncepts with clinical expert panels, specification of 

the concept using various data sources (e.g., claims data, electronic health records (EHRs)), field testing 

the measures across an array of providers with different data systems, assessing the measurement 

properties (reliability, validity of the measure), and finalizing the specification for uniform application 

across physicians in different settings. Because of the high stakes application of measures for payment 

and for driving provider performance, the measure development work should undergo a peer review 

process-rneaning that the work of the measure developers and clinical panels should be published in 

clinical journals or in other publications that rely on a similar review process. Transparency of the process 

and underlying science will enhance the face validity of the process and the acceptability by the clinical 

community. 

6. The legislative draft puts a heavy emphasis on best practices as decided by medical 

specialties and primary care as the bed rock upon which measures should be founded. 

Your testimony also states that CMS should establish a process where measure 

development experts work with clinical speCialties to identify performance gap areas and 

work to address those as measures. In your opinion, how important is this iterative 

relationship between CMS and medical providers around developing and maintaining a 

system of value-based performance? 

Those who measure and those who are measured need to be involved together in developing the system 

of value-based performance-so I would say the iterative relationship is critical. Successful VBP 

programs employ this partnership and it extends beyond identifying/developing measures to working in 

oollaboration to improve. Fundamentally, this is the ooncept behind ACOs, which have the payer (i.e., 

CMS), physicians and hospitals all at the table working together to solve the problem. This relationship 

5 
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85440.100

will be critical to the success of new value-based performance payment systems. Physicians will offer 

important insights on patients who should be excluded from a measure, what is a reasonable 

performance target (given other factors that influence the result), and where the performance gaps are. 

They have deep knowledge of the science and this information is critical to developing a measure that is 

meaningful. For example, recent research conducted by Dr. Eve Kerr at the University of Michigan (Ann 

Arbor Veteran's Administration) shows that performance measurement should be moving towards "riskbased" measurement to avoid over treating patients; her work is showing that physicians are working to 

get HbA 1 c levels in diabetics below values of 7 and 8, often with little clinical benefit to the patient and 

substantial side effects. Such knowledge emanating from clinicians engaged in quality of care is vital to 

the construction of sound measures that Medicare can advance in the context of VBP. Medicare can best 

work to change physician culture by helping physicians understand that Medicare is working ill 

partnership with physicians to do this, rather than simply imposing change on them. Development of the 

measures is the first step in building a partnership built on credibility and respect. 

7. Do you believe Medicare can benefit from thought leaders like Independent Health and 

others who are currently employing new models of care delivery in the marketplace? 

Absolutely! There are important innovations in play throughout the country and the Medicare program 

(which faces more statutory and regulatory constraints that impede its ability to experiment quickly and 

nimbly) should actively monitor and seek to learn from innovation that is occurring in the private sector. 

Much is being learned on the ground by organizations like Independent Health, Dartmouth Hitchcock, 

Aurora Healthcare, Hill Physicians, Sharp Healthcare, Geisinger, Mayo Clinic, Intermountain, etc., and 

unfortunately most of these insights are not being published. CMS should engage in annual outreach 

efforts to providers and payers around the country to leam from the innovations that are happening that 

could inform what Medicare does. 

8. How important is meaningful, timely feedback on performance for such a system to work? 

To take quality improvement action, physicians will need timely feedback on their performance and how 

they vary compared to peers. Generally, the sponsors of incentive programs are not in the business of 

providing real-time information; instead, that has fallen to the organization within which the physician 

works because the organization is better equipped to provide real time information. If the VBP program in 

the physician fee schedule were to establish fixed performance benchmarks that are known long in 

advance of the performance measurement year, physicians could periodically monitor their own 

performance throughout the year to get more immediate feedback. A key challenge in American 

healthcare is that most providers (save for systems like Kaiser and Geisinger) do not have ready access 

to a dashboard of performance indicators to tell them how they are doing in managing their patient 

6 
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85440.101

population. I fundamentally believe that embedding VBP into the physician fee schedule and other 

performance-based payment innovations (ACOs, bundled payments, medical homes) will work to change 

this; over the last decade, Kaiser has transformed itself to have a dashboard of performance indicators to 

be able to respond to VBP-such as in the Medicare Advantage star rating program. Increasingly, in the 

context of ACOs, health plans are partnering with health systems (physicians and hospitals) to provide 

daily reports to alert physicians that a patient's situation is worsening (so at risk for hospitalization) or that 

the patient has been admitted to the hospital or emergency department. Such data are valuable to the 

physician practice so they can intervene quickly to manage the patient in the most appropriate setting. 

Similarly, some integrated health systems are providing real time feedback to physicians on their 

performance (e.g., monthly), flagging areas where performance is lagging or signals a problem. While 

ideally real time data monitoring and feedback would be universal in our health system, that is not a near 

term reality. However, as electronic data systems improve and CMS is able to leverage data submissions 

from physiCians on a more frequent basis, there is potential to develop systems where CMS could 

generate more timely feedback raports (relative to benchmarks)--such as on a quarterly basis. 

The Honorable John Shimkus: 

1. Page 21 of the legislative framework released last week calls for the development of a 

"process by which physicians, medical societies, health care provider organizations, and 

other entities may propose" Alternative Payment Models for adoption and use in the 

Medicare program, Do you believe that model development from private payers and 

providers like those at Independent Health can lead to reforms that could benefit patients, 

providers, and taxpayers? 

I believe that physicians should have flexibility to participate in alternative performance-based payment 

models, be they ACOs, medical homes, bundled payments for episodes of care, or other modals that 

have not yet been developed---and that these should "qualify" physicians as meeting the requirements of 

VBP as they will be measured on a set of performance measures. There is much innovation going on 

nationally in the private sector, such as at Independent Health, and as these types of models emerge and 

show benefit, CMS should consider ways to embed similar features into the Medicare program. Private 

payers, working with local providers, have greater flexibility and nimbleness to innovate, and the lessons 

from these experiments could yield benefits if applied in Medicare. 

The Honorable Gus Bilirakis: 

1. In your testimony, you talk about a continuum of performance. Should we have a target 

percentage for performance of quality measures? For example, should the average of 

7 
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physicians meet 75% or 85% of performance measures? If we do use targets for 

performance measures and the averages are above the target percentage, should we 

recalibrate the metrics every five years or so, to adjust the metrics and increase the 

standards of care? 

I encourage the committee to examine the way in which targets are set in the Alternative Quality Contract 

(Blue Cross Blue Shield of Massachusetts), where targets are set based on empirically derived cut points 

based on the data.' In this program, they pay along the continuum, so providers are rewarded for each 

increment of improvement. The highest level benchmark is set for what is best in class and is achievable, 

based on the actual performance of peer specialty physicians. They have found the highest level tends 

not to change over time (unless there is a significant change in the underlying therapy). Congress or the 

Secretary should set a minimum performance threshold below which no incentives would be paid. 

Performance targets do need to be periodically reviewed and reset; however, the Medicare program 

should seek stability and thus only change targets as necessary. Specifically, a framework should be put 

in place that allows for measures to be updated as needed. There are some measures in place now that 

are being achieved by almost all physicians. As measures top out, CMS should be empowered to retire 

those measures and implement new ones that allow physicians to continue to improve and be rewarded 

by such improvements. 

Another approach for setting cut points is to use national benchmarks-such as the National Committee 

for Quality Assurance's (NCQA) Health Employer Data Information Set (HEDIS) measure benchmarks. 

The highest level benchmark can be set for what is best in class and is achievable, based on the actual 

performance of peer specialty physicians. 

I am unclear on the portion of your question about "should the average of physicians meet 75% or 85% of 

performance measures." You may be asking about the use of a composite measure that aggregates 

infomnation across a group of measures. For example, a composite could be constructed by adding 

together all measures for which a physician "passes" the measure divided by all the measure 

opportunities. In this case, you would arrive at the percent of all opportunities achieved. There is ample 

literature on composite construction, and I would be happy to discuss this topic with the subcommittee if 

this is an area of interest. 

2. How much of these quality measures should be developed for the physician in general or 

should we have measures for specific diseases? There are hard to diagnose diseases with 

, Safran, DG et al. Evaluating the Potential for an Empirically-<lerived Standard of Performance Excellence in 

Ambulatory Patient Care Experience Measures: Analysis in Support of NCQA's Efforts to Develop a Physician 

Recognition Program in Patient-Centered Care. October 2007. 

8 
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small populations. If we do develop metrics for specific conditions. how do we responsibly 

develop measurements·for these conditions when research may be more limited? 

Performance measures should be "patient-driven: By that I mean that the patient's health care needs 

define the measure. For some measures, multiple physicians could be accountable for the same measure 

(such as the management of high blood pressure where a primary care physician and a cardiologist could 

be accountable). Many oftoday's measures have a disease or condition focus such as for diabetes, heart 

attack, or congestive heart failure. In these instances, there are multiple evidence-based processes of 

care and intermediate outcome measures that form a collection of measures for diabetes or heart 

disease. What generally drives performance measurement are the following things: 1) prevalence of a 

condition; 2) treatment impact (meaning that there is evidence that doing X will result in improved 

outcomes-better functioning and maintenance of health, lower comorbidity, and lower mortality); 3) 

identification of a gap in care (I.e., underuse); and 4) variation across physicians in care delivered with no 

demonstrable effect on outcomes (I.e., areas of potential overuse of services). 

You flag two critical problems in the area of performance measurement. The issue of small numbers: 

generally measurement has focused on areas where there is greater prevalence of the problem in the 

patient population. Unless there is an opportunity for large impact from addressing care for less prevalent 

conditions, the focus hasn't been on these types of clinical problems. In the future, this may change as 

electronic health records provide a vehicle for providing clinical decision support to ensure that patients 

with less common problems still receive evidence-based care. One strategy for dealing with small 

numbers is to create a composite measure (see above) from all the possible measure areas for a given 

physician; this approach aggregates information across all care provided by the physician. This may be a 

potential approach for clinical subspecialists who deal with less common health conditions. Developing 

measures that are reliable at the individual measure may not be possible, but when aggregated across 

multiple measures, we may be able to get a good signal on the overall quality of care provided by the 

physician. 

3. How much input should patient groups have and what type of input into the process 

should they have when determining these measures? 

Patients are an important stakeholder group that should be consulted at various stages in what gets 

measured. Patients routinely identify issues such as access to care, coordination, communication, and 

costs as key concerns. Currently. patient groups are involved in the NQF's National Priorities Partnership, 

which identifies core areas for measure development. CMS could similarly engage patients at the front 

end of the process to identify key areas for development. 

9 
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4. Should the system evolve to allow a direct feedback loop to the doctor? For example, the 

physician would know that they were paid X because they did or did not do Y to patient Z. 

Do we want that granular a system, or should the information and payment be done on a 

more aggregate level? 

As I mentioned in my response to Chairman Pitts, (see question 8, above), to take quality improvement 

action, physicians will need timely feedback on their performance and how they vary compared to peers. 

Generally, the sponsors of incentive programs are not in the business of providing real-time information; 

instead, that has fallen to the organization within which the physician works because the organization is 

better equipped to provide real time information. If the VBP program in the physician fee schedule were to 

establish fixed performance benchmarks that are known long in advance of the performance 

measurement year, physicians could periodically monitor their own performance throughout the year to 

get more immediate feedback. A key challenge in American healthcare is that most providers (save for 

systems like Kaiser and Geisinger) do not have ready access to a dashboard of performance indicators to 

tell them how they are doing in managing their patient population. I fundamentally believe that embedding 

VBP into the physician fee schedule and other performance-based payment innovations (ACOs, bundled 

payments, medical homes) will work to change this; over the last decade, Kaiser has transformed itself to 

have a dashboard of performance indicators to be able to respond to VBP-such as in the Medicare 

Advantage star rating program. Increasingly, in the context of ACOs, health plans are partnering with 

health systems (physicians and hospitals) to provide daily reports to alert physicians that a patient's 

situation is worsening (so at risk for hospitalization) or that the patient has been admitted to the hospital 

or emergency department. Such data are valuable to the physician practice so they can intervene quickly 

to manage the patient in the most appropriate setting. Similarly, some integrated health systems are 

providing real time feedback to physicians on their performance (e.g., monthly), flagging areas where 

performance is lagging or signals a problem. While ideally real time data monitoring and feedback would 

be universal in our health system, that is not a near term reality. However, as electronic data systems 

improve and CMS is able to leverage data submissions from physicians on a more frequent basis, there 

is potential to develop systems where CMS could generate more timely feedback reports (relative to 

benchmarks )-such as on a quarterly basis. 

5. Is it possible to use phYSician quality measures to encourage patients to better follow a 

doctor's plan to manage diseases? For example, a newly diagnosed diabetic getting a 

follow up call by the doctor reminding them to check their blood sugar or reminding them 

to schedule an appointment with a nutritionist. Should these metrics be limited to what is 

done inside the physiCian's office? 

10 
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85440.105

The question you raise seems to refer to use of patient incentives. VBP programs tend to focus on 

incentives for the physician to do the right thing; however, patients have a significant role to play, and 

some parties are experimenting with the use of patient incentives to encourage their engagement. 

6. Should the quality measures be weighted? If there are 10 things that a doctor can do to 

increase their performance measure, should they be rated equally for payment bonuses or 

weighted to account for time or difficulty? 

There is no single correct answer here. The use of weights can signal "importance" and thus direct 

provider attention to areas deemed more important by payers and other stakeholders. For example, the 

Medicare Advantage program places more weight on outcomes, intermediate weight on patient 

experience measures, and the lowest weight on process measures. These are "policy" derived weights. 

Weighting of measures can be used to encourage greater focus or as you note, provide some accounting 

for level of difficultly. Weights can also be empirically derived (using tools such as factor analysis), based 

on which measures are providing the strongest signal on performance (Le., those measures where the 

reliability of measurement is greatest). The advantage of empirically derived weights is that the program 

sponsor can work to minimize the risk of misclassifying a provider's performance by increasing the 

reliability of the composite measure. Some VBP programs have chosen to assign weights to different 

measure domains in determining payouts, such as 50% on clinical, 20% on patient experience, and 30% 

on safety. In this case, these represent the values of the stakeholders involved in the program. The use of 

weights is a policy option that should be left to the discretion of the Secretary, who should consult with 

affected stakeholders. Note that in any measurement system, even if all measures receive a weight of 1, 

if there are more diabetes measures (let's say they represent 5 out of a total of 10 measures), then de 

facto they will account for 50% of the total weight in an equal weight scheme. 

The Honorable John D. Dingell: 

1. During the hearing, you agreed that Congress should look at the innovations and changes being 

made in the private sector when considering reforms to SGR. Would you please list some 

suggestions of what you feel might be useful? 

The types of changes being envisioned in reforming the SGR at this stage are reflective of early pay for 

performance (P4P) efforts over the past decade, where physicians were paid differentially (at the margin) 

for a set of measures. Much has been learned from these P4P experiments---and I would encourage 

Congress to examine the California Integrated Healthcare Association P4P program and the P4P efforts 

by private plans in Massachusetts. In California, the program is evolving to include costs, and it will now 

be called the value-based pay for performance program; in this program providers have to hit both cost 

11 
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and quality targets and incentives will be based on shared savings. Such an approach could be 

considered in SGR reforms, once an established program of performance measurement is put in place 

(the first building block). In the near term, if Congress wants physicians to focus on helping to reduce 

health spending, measure development needs to prioritize the development of measures of overuse. 

Additionally, physicians need to understand where they deviate in the delivery of care and what factors 

contribute to them being high cost outliers (after controlling for the difficultly of their patient mix). These 

are the types of actions that are in play by numerous private payers and provider organizations-such as 

United Healthcare, Blue Cross Blue Shield of Massachusetts, Kaiser, Mayo Clinic, Aurora Healthcare, the 

Palo Alto Medical Foundation (and Sutter Medical Group). In constructing the bill, Congress should 

outline the path for physicians and set expectations that measurement in the early term may focus on 

closing quality gaps (underuse of services), but over the longer term focus on cost reduction through 

variation reduction and reduction in the overuse of low value services. This is the focus in the private 

market, and ACOs are working aggressively on these areas to ensure they meet targets to secure shared 

savings. 

12 
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85440.107

Mr. Bill Kramer 

Exe.cutive Din?c-{or for Nationa1 Health Policy 

PacifIC: Bu::'Oiness- Group- on Health 

22! rv1ain Strcct~ Suite 1500 

S"" Francisco. C A 941 05 

Dcar iVlr. Krcunec 

June :::6~ 2013 

rhank you f~w appearing bd~-xe the Subconlmine(' on Health ,')H \Vcdllesday. Juno,; 5. 2013, to 

tcsrif)' at the hearing cnlilk~d ~~Ref()-fming SUR: Prioritizing Quality in a rVlodcrnized Ph)Slciml Pa)-mcnt 

s.ystern.'~ 

Pursuant to lh-t.~ Ru1c-s of the COTIlmittcc on Energy .and Con1nl-crcc~ the hcnring recDrd remains 

open fix ten busincfis days to permit ~4embcrs to submit additional questions for the rccord~ which are 

Hauchcd. The fonnatofyour re:-:;p{}ns-c~ to these questions should be as foBows: 0) the nHm(;.~ of the 

~1crnher whose question you arc addressing, (2) the complete 1exl of the question you afC addressing in 

ho-kL and (3) your fmS\\'Cr to that ques-tion in plain text. 

Ah.o aHached -arc \!h:."mbcr reqnests made during the hearing. The fbnl1at of your responses to 

these rcquc-'Sts should follrHv the same format as your responses to the additional questIons rex the record, 

To fhdlitatc the printing, of the hearing record. please respond to these quc::;tions iUld Tcque::;lS by 

the dose of business on Friday. July 11~ 20 J], Your ft!sponscs should be mailed to Sydnc Harwick~ 

l~egis.iath'e Clerk. CmnluiUee on Energy and C-t"mnlcrcc," 2125 R ... '1ybu!11 H(.use Office Building. 

\Voshin-gton" D.C. 10515 and c-rnailcd In \Vor,d fbnnat to Svdnc.Harv.-i;-cI,/Q->tuail.hous-c.gov. 

Thank you again for your time and effort preparing and ddiv\.;l·ing tcstim<>ny before thl'-

Subcommittee. 

Since"dy, ") ? ~ 

S~itts hairman 

ubcomminec on Ifeahh 

c.'c: The Honorable Frank PuHon-e, Je. Ranking ~vfcmhcr, Subcommittee on Health 

A.tw..;:tuTlcntS-
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85440.108

Attachment 1 - Additional Questions for the Record 

Responses from William E. Kramer. 

Executive Director for National Health Policy 

Paci fic Business Group on Health 

July 24.2013 

The Honorable John Shimkus 

1. Page 21 of the legislative framework released last week caIls for the development of 

a "process by which physicians, medical societies, health care proyider 

organizations, and other entities may propose" Alternative Payment Models for 

adoption and use in the Medicare program. Tell me, do you believe that model 

development from private payers and providers like those at Independent health 

can lead to reforms that could benefit patients, providers, and taxpayers? 

Response: Yes. Private health plans. provider groups. employers and other organizations 

have developed a wide range of innovative provider payment models. The best of these 

provide appropriate incentives for improvcd quality. patient experience, appropriateness 

and efficiency of the services provided. These models benefit patients, purchasers and 

taxpayers by cncouraging providers to deliver services that result in higher value - better 

quality and lower cost. The innovative payment models also reward physicians who are 

delivering superior medical care. 

Note: See response to the question from The Honorable John D. Dingell. Attachment 2, 

for morc details regarding innovative private sector payment programs. 

The Honorable Gus Bilirakis 

1. How much of these quality measures should he developed for the physician in 

general or should we have measures for specific diseases? How do we develop 

quality measures for rare diseases? These are hard to diagnose diseases with small 

populations. If we do develop metrics for specific conditions, how do we responsibly 

develop measurements for these conditions when research may be more limited? 

Response: We need both general and specific measurcs. 

• General performance measures are needed to compare physicians regardless of 

their spccialties and of the specific disease being treated. First, patients expect 

the same high quality of care from any doctor integrally involved in treating their 

condition. For example, a patient treated by a primary care physician for diabetes 

should expect to get the same care as a patient treated by a specialist. Otherwise, 

there is one standard for primary care physicians and another standard for 

pulmonologistS. A patient-centered approach is to apply measures to all 

physicians that may be caring for patients with a panicular condition. Otherwise, 

we are not getting a true picture of quality, and variation across peer groups is 

accepted. Second, general measures of performance are needed by patients and 

purchasers to evaluate the overall quality of care provided by an individual 
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85440.109

physician or medical group. For example, patients choosing among competing 

ACOs want to know whether the ACO's physicians, as a group, are rated high for 

coordinating the care of their patients. This is important information regardless 

of the specific disease or condition, especially for patients who do not have an 

existing or chronic condition. 

• Specific performance measures for certain conditions are also needed. For 

example, a prospective mother will want to know which obstetricians have the 

best clinical outcomes for deliveries. If the patient has had a previous C-section 

delivery, she will want to know whether the obstetrician is likely to recommend 

another C-section vs. a vaginal birth. Specific information like this would be 

masked by general performance measures. 

2. How much input should patient groups have and what type of input into the process 

should they have when determining these measures? 

Response: Performance information is a public good, and it should be developed in order 

to meet the public interest. Measures that are used in this program should include those 

that are relevant and meaningful to purchasers and consumers. These types of measures 

are often lacking in measures developed solely by provider organizations. For more 

information, refer to Ten Criteria for lvfeaning{U1 and Usable Measures o(Performance. 

While physician involvement is critical in this process, the ultimate stakeholders are 

those who receive and pay for medical care. 

Patient representatives can bring the authentic voice of the patient into the process of 

defining and evaluating quality. Patients often make trade-off's that differ from those 

made by clinicians. Research shows, for example, that patients often choose more 

conservative treatment options when using shared decision-making tools and when 

considering end-of-life care. Excellent methods exist for scientific measurement of 

patient outcomes and preferences that should be included in the measurement 

development process. Patient organizations should be asked to help define "quality" for a 

given condition and to encourage patients to contribute their own data to the quality 

measurement process, through surveys and patient-reported outcome measures. 

3. Should the system evolve to allow a direct feedback loop to the doctor? For example, 

the physician would know that they were paid X because they did or did not do Y to 

patient Z. Do we want that granular a system, or should the information and 

payment be done on a more aggregate level? 

Response: In response to a question from the Committee during the June 5 hearing, I 

stated that, ideally. physicians would receive real-time feedback on their perfonnance as 

well as real-time decision support tools. For example, a primary care physician would be 

able to see, every day, how many of her or his patients had acceptable blood pressure 

levels. The physician would also be able to see the expected costs of diagnostic and 

treatment options, e.g., lab tests, imaging and prescriptions, before making decisions in 

the best interests of the patient. CUITent rep0l1ing methods, however, often have a very 

long lag - sometimes as much as a year after services are delivered. Retrospective 
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85440.110

reporting with long lags is not very useful to clinicians who are working every day to 

improve the care they provide. 

Including the amount the physician would be paid tor every decision is problematic. 

Physicians have an obligation to serve their patients, and information about the likely 

outcomes and potential risks as well as costs and resource use - should be paramount 

when making decisions. We SUpp0l1 frequent and convenient provision of aggregate cosl 

and resource use data to physicians. but do nol recommend patient-specific cost data that 

may intluence physician judgment. 

4. Is it possible to use physician quality measures to encourage patients to better follow 

doctor's plan to manage diseases? For example, a newly diagnose diabetic getting a 

follow up call by the doctor reminding them to check their blood sugar or reminding 

them to schedule an appointment with a nutritionist. Should these metrics be limited 

to what is done inside the physician's office'? 

Response: Yes, quality measures should be used to encourage better follow-up care. For 

example. managing blood glucose levels is essential for diabetic patients. Measures 

should not be limited. however. to what is done in the physician's office. Managing a 

chronic condition like diabetes requires communication and an effective partnership 

bel ween the physician and the patient, much of which happens outside the visit to the 

physician's ottice. 

Physicians should be rewarded for achieving superior Q!1tcomes -- e.g .• do their diabetic 

patients have acceptable blood glucose levels -- not "process" measures such as followup calls or reminders. There are many ways to achieve good outcomes; overreliance on 

standardized process measures may deter important innovation, fail to recognize local 

health care market and populations differences, and lock in the care processes oftoday 

that may not be the most useful and effective tomorrow. 

Public reporting and payment programs should focus on outcomes and other patientcentered performance measures. Improvement will result from providers' efforts and 

innovative approaches to achieve superior outcomes. 

5, Should the quality measures be weighted? If there are 10 things that a doctor can do 

to increase their performance measure, should they be rated equally for payment 

bonuses or weighted to account for time or difficulty? 

Response: Yes, it is appropriate to consider different weights for performance measures. 

The relative weights, however. should be based on importance to patients. not the time or 

diHiculty involved in achieving high levels of performance. The public interest should be 

paramount in selecting and lIsing performance measllres in Medicare physician payment 

programs. 
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85440.111

Attachment 2-Membcr Requests for the Record 

During th~ h~aril1g Members askedHJII to pro\'ide additional iI(formationfi)l" the record. am/you 

indicated that ),011 11'01l1d proi'id~ that iI((iJrmatiol1. For your cOI71·~l1i""ce. descriptirms of the 

reqllnled in(imnutiol1 ar~ jlmrided below, 

The Honorable John D. Dingell 

1. During the hearing, you agreed that Congress should look at the innovations and 

changes being made in the private sector when considering reforms to SGR. Would 

you please list some suggestions of what you feel might be useful? 

Response: Large employers have supported innovative approaches to physician payment, 

such as the Intensive Outpatient Care Program (IOCP) piloted by Boeing and adopted by 

other large employers.' The IOCP is a primary care-led, high intensity care management 

model for high-risk populations. The California HealthCare Foundation (CHCF) provided 

the funding to develop this ground breaking model of delivering care as a strategy for 

reducing costs while maintaining or improving quality. The designs and financial 

projections underwent a peer review panel of subject matter experts and leaders of 

traditional and more innovative practices. Key features of the model include: 

A focus on high-risk patients, i.e., the 5-20% who incur the highest costs. 

Each site creating a new ambulatory intensivist practice. 

Shared care plans, increased access, and proactively managed care. 

• Copays for the initial intake visit were waived; there were no other benefit 

changes. 

Sites were paid a case rate per member per month (pmpm) to cover nontraditional services; otherwise, the sites continued to be paid based on 

traditional fee-for-service contracts. 

The sites received a portion of the savings in total medical expenses. 

The Boeing Company initially implemented a pilot of this model in Seattle. Over a twoyear period, Boeing achieved improved health outcomes (28% reduction in hospital 

admissions, 16% increase in mental functioning on the SF-36), 20% reduction in costs, 

and increased patient access to care. i, iii 

Following the success of the Boeing pilot, PBGH worked with CalPERS and Pacific Gas 

& Electric Company (PG&E) to replicate the model in rural Northern California with the 

Humboldt del Norte Foundation Medical Group. This program targets the top 20 percent 

of patients in terms of relative health risk. PBGH is now expanding the IOCP to the 

Medicare population. Under a grant from the CMMI, PBGH is rolling out this model to 

17 medical groups in California, covering 23,000 Medicare patients, demonstrating 

commitment to public and private sector alignment.'v 

Other PBGH members are experimenting with models for accountable care organizations 

(A CO). For instance, CaIPERS implemented an ACO-like pilot with Hill Physicians 

Medical Group, Dignity Health and Blue Shield of California that introduced a shared 
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85440.112

savings model for improving care coordination and quality for 42,000 HMO beneficiaries 

in the greater Sacramento area. Early results showed a $15.5 million cost reduction 

annually due to a 17% reduction in patient readmissions and shorter lengths of stay. v 

Five months later, those results were updated to reflect $20 million cost reduction over 

the two years of the program, largely due to a 22% reduction in hospital 

readmissions. VI VlI 

Large employers know, however, that these innovations do not have the scale to drive 

system-wide change and improve health care across the nation. It is important to have the 

collaboration of the federal government the nation's largest health care purchaser -- in 

transforming the way health care is delivered. Working together is also important to large 

employers to avoid the shifting of costs from the public to the private sector. In some 

markets, cost shifting from Medicare to private payers can be as high as 40%. v.ii ix x 

Instead, we should pursue strategies to improve quality while lowering the overall cost of 

care. 

I Additional infonnation about the IOCP program can be found at http://w\\,w.pbgh.orgliocp. 

i, Milstein, A and Kothari P, Health Affairs. October 20. 2009. Accessed at http://bealthaffairs.org/blog/2009/10/20/arehighcr-.... aluc-carc-models-replicablci 

III This model was also highlighted in Atul Gawande's "Hot Spotters" article in the New Yorker, and documented on 

the Agency for Healthcare Research and Quality (AHRQ) Health Care Innovations Exchange. 

http://w\',:w.innovations.ahrq.gov/content.aspx?id=2941. Additionally, Steve Jacobson, MD and Jennifer WilsonNorton of The Everett Clinic presented on "Connecting Providers and Managing High Risk Beneficiaries" at the eMS 

ACO Accelerated Development Learning Session on September 16.2011, 

https:l/acorcgister.rti,orgldocx/dspJnks.cfm?doc=ModuJe 3B. Connecting Providers Managing High Riskpdf. 

l' http://\Vwv.,'.pbgh.org/key~strategies/paying-f()r-value/28-aicu-personalized-care-for-complex-patients. 

'CaIPERS Press Release. (201 I. April 12). Press Release: April 12,201 I. Retrieved February 21. 2012. from 

V-l\VW ,calpers.ca.gov: hUp:/ !v.'w\v ,calpers.ca.gov/indcx.jsp?bco'c/aboutipress/pr-20 II/april/integrated ~hcalth.xml. 

n CalPERS Agenda Item 4. (201 I. October 18). Agenda Item 4 Memo to the Members of the Health Benefits 

Committee, Retrieved February 21. 20ll, from \\'ww.calpers,ca.gov: http://\v\-Iow.calpers,ca,gov/eip-docs/aboutJboardcalagendaJagcndas/hbc!20111Q!itcm-4 pdf. 

no Dlue Shield of California Press Release. (201 I. September \6). HHS Secretary Kathleen Sebc1ius Reviews Key Pilot 

Program Tied to Health Care Refonn Goals. Retrieved June 3, 2013, from www.blueshieldca.com: 

https:!/w,V\".bluc5hjeldca.com/bscaJabout-blue~shield/ne"vsroom/sebelius-reviews-aco-pilot-programs.sp. 

'1Il W Fox & J Pickering. Cost Efficiency at Hospital Facilities in California: A Report Ba"ed on Publicly Available 

Data. Milliman. Oct 2007. 

IX Analysis of Hospital Cost Shift in Arizona. '(be Lewin Group. March 2009. 

x Health Care Trends in America. BlueCross BlucShield Association. 2009 Edition. 
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l>L JelT,ev B. Rich 

i\4id-i\tial~ltk {~.ardiothoracic Surgeons 

S-cntara Hemt Hospital 

600 Gresham Drive, Suile S600 

Kori()lk, V A 21507 

DcaI' Dr. Kich: 

June 26, 2013 

Thank yen for appearing hc1hre tile: SubemTlinittee on Heahh on \Vcdncsdny, June 5~ 2013, to 

u.,;:,:tif): at the hearing entitled ·~Reforming SGR: Prioritizing Quality in a l\1odcrnizc-d PhysIcian Payment 

Syslcm.~· 

PUfs,llanl to the RuJes of the Committ.:r::. on En-crhy)' and Commcrcc* the hearing 11..."'Coni remain:; 

open for ten business days to permit !\1euthcfS 1"0 submit ad.ditional questions. for the rccord~ \,-hkh are 

attt}ched. The j'(xmat of your res.ponses to these quc!:Ilions should be as follows: (1) the name of the 

:\:lelnber ..,,-,hose question you .arc addressing. (2) the complete text of the question you are a-ddrc-:o;sing in 

ho.IJ~ and (3) your anS\Vcr to that question in plain lest. 

Also attached are Member requc5;ts l'nadc during the hearing" fhe fcwma1ufyuuf rcsponses to 

these requests should f(JUoW the same fOrInat a-,:.; your responses: to dll~ additional questions for the record. 

To faciHtate the printing of the hearing. rccord~ please respond to these questions and requests by 

the dose ofbu5incs~ on Fridtly. July 12.2013. Your responses should be mailed to Sydnc Hurwick. 

L..:gis:lutivc Clcrk~ Committee on Energy and Comnlerc-e~ 2125 Rayburn I-ious-e Office Building, 

\Vac;hingwn, D.C, 20515 ."md e-maUed in \Vord f'tlrmat to Svdnc.Hanvickfit:'mail.house.go\,-* 

Thank you again for your tIme and eff0I1 preparing and dL'Hvcring testimony befi.11"C' the 

Snocommittee. 

Silll..:erely, 

7?, 

I J)Sc Ie l'ilts 

'haimum 

! );ubcmnmiUcc on Health 

".,,/" 

cc: The Honorable Frank Panonc~ Jr., Rim king Yh'mb~r. Subcommittee on Health 

;\1tachments. 
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85440.114

The Society of 

Thoracic Surgeons 

STS Headquarters 

633 N Saint Cla)rSt. Flo(}r23 

STS Washington Office 

20FStNW,Ste310C 

www.sts.org 

July 12,2013 

Honorable Joseph R. Pitts 

Chairman 

Committee on Energy and Commerce 

Subcommittee on Health 

U.S. House of Representatives 

2125 Rayburn House Office Building 

Washington, DC 20515 

Honorable Frank Pallone 

Ranking Member 

Committee on Energy and Commerce 

Subcommittee on Health 

U.S. House of Representatives 

2125 Rayburn House Office Building 

Washington, DC 20515 

Dear Chairman Pitts and Ranking Member Pallone: 

Thank you for the opportunity to present my testimony on behalf of The 

Society of Thoracic Surgeons (STS) and thank you for your thoughtful 

questions. As you know, STS is the largest organization representing 

cardiothoracic surgeons in the United States and the world. Founded in 1964, 

STS is an international, not-for-profit organization representing more than 

6,600 surgeons, researchers, and allied health care professionals in 85 

countries who are dedicated to providing patient-centered high quality care to 

patients with chest and cardiovascular diseases. including heart, lung, 

esophagus, transplantation, and critical care. The mission of the Society is to 

enhance the ability of cardiothoracic surgeons to provide the highest quality 

patient care through education, research, and advocacy. 

Additional Questions for the Record 

The Honorable Joseph R. Pitts 

1. From your testimony, it appears that the Society of Thoracic Surgeons 

have been doing measurement development and promotion for years. Do 

you believe that specialties that may not be as advanced as thoracic 

surgery can catch up? 

Yes, in fact many specialties are already in the process of developing their 

own, specialty-specific clinical registries. Importantly, we believe that 

implementation of a pay-for-quality program should not wait for all of 

medicine to be at the same place at the same time. We recommend that 

policymakers consider ways to reward providers for incremental steps towards 

these quality assessment goals outlined in Phase II ofthe Committee's 

discussion draft, while allowing those medical specialties that already have the 

requisite infrastructure in place to engage in this new system as soon as 

possible and reap some reward for their efforts. 

Short, medium, and long term infrastructure, measure, and quality assessment 

benchmarks should be set up as intermediate goals, shortening the "period of 

stability" for those able to meet those steps. For example, incremental steps 

towards Phase II readiness can include reporting of data to a clinical database 
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Chairman Pitts and Ranking Member Pallone 

Page 2 

under construction, working on various "Clinical Improvement Activities" as defined in the 

Committees' concept document, receiving feedback on quality measure performance (even while 

such measures are being considered for approval), or observing process or structural measures 

that have been approved or are in the process of being approved by a consensus-based entity, 

among others. 

2. How beneficial can a system of primary care and specialty-specific quality and efficiency 

measures be to our seniors, taxpayers, and the Medicare program as a whole? 

The fundamental principle underlying the STS database initiative has been that engagement in 

the process of collecting infonnation on every case, robust risk-adjustment based on pooled 

national data, and feedback of these risk-adjusted data to the individual practice and institution 

will provide the most powerful mechanism to change and improve the practice of cardiothoracic 

surgery for the benefit of patients and the pUblic. In fact, published studies indicate that the 

quality of care has already improved as a result of research and feedback from the STS National 

Database. 

For example, EIBardissi and colleagues studied 1,497,254 patients who underwent isolated 

primary Coronary Artery Bypass Graft (CAB G) surgery at STS National Database-participating 

institutions from 2000 to 2009. They found that: 

Patients received more indicated care processes in recent years, including a 7.8% 

increase in the use of angiotension-converting enzyme inhibitors preoperatively and a 

significant increase in the use of the internal thoracic artery (88% in 2000 vs. 95% in 

2009). 

The observed mortality rate over this period declined from 2.4% in 2000 to 1.9% in 

2009, representing a relative risk reduction of 24.4% despite the predicted mortality 

rates (2.3%) remaining consistent between 2000 and 2009. 

The incidence of postoperative stroke decreased significantly from 1.6% (2000) to 

1.2% (2009), representing a relative risk reduction of 26.4%. 

There was also a 9.2% relative reduction in the risk of reoperation for bleeding and a 

32.9% relative risk reduction in the incidence of sternal wound infection from 2000 to 

2009. 

In addition, participation in initiatives that rely on data from the STS National Database have 

proven that access to information on patient outcomes helps physicians to identifY best practices 

in quality and efficiency that can help save money and critical resources. For example, funded by 

the National Heart Lung and Blood Institute (NHLBI) at the National Institutes of Health (NIH), 

the ASCERT (American College of Cardiology Foundation-The Society of Thoracic Surgeons 

Collaboration on the Comparative Effectiveness of Rev as cuI ariz at ion Strategies) study was 

designed to examine the comparative long-tenn effectiveness of Coronary Artery Bypass Graft 

(CAB G) and percutaneous coronary intervention (PCI) revascularization strategies in real world 

populations, including specific subgroups of patients such as those with diabetes, severely 

impaired heart function (low ejection fractions), chronic lung disease, and kidney dysfunction. 

ASCERT examined 86,244 patients undergoing CABG and 103,549 patients treated with PCI. 

The study uses data from STS Database and ACC registry along with CMS Medicare Provider 
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Chainnan Pitts and Ranking Member Pallone 

Page 3 

Analysis and Review (MEDPAR) data. STS views the ASCERT study as a paradigm for a 

comparative effectiveness research enterprise based on linked clinical and administrative data. 

Clinically robust, broadly generalizable data from thousands of patients, linked with longitudinal 

outcomes from claims data, could quickly and cost-effectively answer a broad range of 

questions. The results of these studies will be a unique and innovative source of infonnation for 

patients, providers and various third party payers concerning the potential long-term results of 

different treatments in specific subgroups. Such infonnation could feasibly be used to change 

how physicians treat their patients, patients experience their treatments, and payors reimburse for 

care. 

At the regional level, the Virginia Cardiac Surgery Quality Initiative (VCSQI) has demonstrated 

that improving quality reduces cost. For example, using evidence-based guidelines derived from 

an analysis of data from the STS National Database combined with patients' claims data, VCSQI 

has generated more than $43 million in savings through blood product conservation efforts and 

more than $20 million by providing the best treatment to patients with atrial fibrillation at the 

right time. 

3. You mention in your testimony the importance of linking administrative and outcome 

data for providers in the field. How important in such a process as outlined in the 

Committees legislative framework will it be for providers to have timely access to their own 

performance data? How early and often in the process of measurement should such access 

happen? 

The issue oflinking robust clinical data with resource utilization data such as Medicare or 

private payor claims infonnation is an essential part of any program that attempts to improve 

quality and efficiency in health care. Clinical data registries have previously been limited to 

short-tenn outcomes. To mitigate this limitation, STS has linked our clinical registry data to 

administrative sources such as CMS MEDPAR to obtain long tenn clinical outcomes and long 

tenn data on resource utilization. Clinical registries provide detailed diagnostic and therapeutic 

data (including data about risk factors and severity of disease) not present in administrative 

databases, while administrative databases provide infonnation about long-tenn outcomes and 

cost not present in clinical databases. Linkage of clinical and administrative databases is 

essential for the assessment of resource use and value (quality/cost). The linkage of clinical data 

with resource utilization data provides the mechanism to risk-adjust both clinical outcomes and 

resource utilization and thereby to assess the value of care being delivered. We anticipate that 

feedback ofthese linked clinical and resource utilization data to the practice/institutional level 

will be associated with further improvements in both the quality and cost, i.e., value of 

cardiothoracic surgical practice. We urge that the CMS MEDPAR data be made available on a 

regular basis to qualified registries that have robust patient privacy protections and formalized 

standards for assessment of providers' performance that relies on both clinical and claims data, 

such as the STS National Database. 

A significant roadblock to the acquisition oflong-tenn survival data has recently been 

established by the Social Security Administration. In November 2011, the Social Security 

Administration rescinded its policy of sharing state-reported death data as a part of the Social 

Security Death Master File (SSDMF). There are continuing efforts to further restrict access to 
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Chainnan Pitts and Ranking Member Pallone 

Page 4 

the SSDMF so as to "protect" those listed in the file trom identity theft. Balanced against these 

legitimate privacy concerns is the value of the unique survival information that can be provided 

from the SSDMF data. Linking clinical registries to the SSDMF allows for the verification of 

'life status" of patients who otherwise would be lost for follow up after their treatment, and as 

indicated previously, this longitudinal survival data is vital in assessing the long tenn efficacy of 

many treatment algorithms for important diseases, including heart disease, cancer, and many 

other chronic diseases. 

Research based on this infonnation helps physicians to provide infonnation to today's patients 

and families to help them with shared decision making. Outcomes data give patients confidence 

in their medical interventions and demonstrate to patients and their families the durability and 

long-tenn benefits of medical procedures. It is important to note that STS, through its contracts 

with the Duke Clinical Research Institute, rnaintains the patient identifier data separately from 

the actual clinical and other demographic data, and the only patient level identified infonnation 

that ever leaves the database is simply that the patient has a record in the database. When the 

follow-up infonnation is returned from external entities, such as the SSDMF, it can be linked 

back to the records in the de-identified database, but the flow of infonnation is only in this 

direction. The externally derived data are used to supplement the data in the individual record, 

but these data never leaves the database except in de-identified fonn. 

Importantly, STS believes that rneaningful quality measures and rewards for physician 

perfonnance cannot be applied simply to administrative data, including claims data, reported by 

hospitals and physicians alone. While administrative data provide infonnation on longitudinal 

medical treatments and resource utilization across settings of care and by various physicians, 

their clinical accuracy have been shown to be poor, and they exclude pertinent infonnation on 

patient risk factors, disease severity, and clinical outcomes. This critical infonnation is only 

found in clinical datasets where there is input of clinical data by clinicians. Publication of claims 

data, without the clinical context and robust demographic information essential to riskadjustment, could have extremely hannful effects. For that reason we oppose current efforts by 

the administration to provide general public access to Medicare Claims data and request 

significant revisions to S. 1180 and/or any similar legislation that is considered in the House. 

Finally, in responding to this question, we feel it is important to define the tenns physicianreported data, physician perfonnance based on quality measures, and physician feedback reports. 

I have provided an example of a physician data entry fonn (available here: 

http://v.'Ww.sts.org/sites/defauit/files/documents/STSAdultCVDataCoilectionFonn2 73 Annotat 

ed.pdf) and a physician feedback report (available here: 

http://www.sts.org/sites/default/files/documents/pdf/ndb20 1 O/Report OV General 5-37.pdf). 

You will note that the data collection fonn records raw data drawn from a patient's chart. Quality 

measures provide statistically and clinically relevant ways to interpret those data. The feedback 

report uses these data and measures to generate analyses across the specialty, allowing 

cardiothoracic surgeons to compare themselves against national aggregate data in a statistically 

valid and clinically credible fashion. We wish to again emphasize the motivational power of this 

type of feedback data in influencing physician practice. 
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Chairman Pitts and Ranking Member Pallone 

Page 5 

4. Your testimony and past feedback to this committee raised a concern about the sharing 

of best practices should a system of quality measurement be linked to payment in the 

wrong way. Do you have any recommendations for appropriate ways to apply such 

measurement that would not negatively impact the sharing of best practices among 

providers? 

While the creation of a reward/penalty system of physician reimbursement is not inherently 

wrong and could potentially be an effective method of improving health care quality and 

efficiency, it is the method of implementation that is logistically problematic. If such a system is 

designed to operate on the individual physician level, intra- and inter-hospital cooperation and 

sharing of best practices will almost certainly suffer. In addition, from a purely statistical 

perspective when low frequency events are being evaluated, it is virtually impossible to 

distinguish different levels of performance between one clinician and another because the total 

number of patients / outcomes / events created by the individual practitioners is far too small to 

yield any meaningful interpretation. For example: 95% of25 patients equals 23.75 and 92% of 

25 patients is 23 (essentially no difference). However, 95% of 10,000 patients equals 9500 and 

92% of 10,000 is 9200 (a much more easily appreciated difference). On the other hand, a 

national or perhaps regional construct will enhance cooperation and "cross-fertilization" of 

information. Cardiothoracic surgical examples ofthese structures include not only the STS 

National Database efforts, but also state and regional efforts such as the Virginia Cardiac 

Surgical Quality Initiative, the Michigan STS collaboration on adult cardiac surgery, and the 

Northern New England Cardiovascular Study Group. Placing incentives at a higher 

organizational level (e.g. state, region, or national) can encourage collaborative learning and 

quality improvement that should be inherent aspects of professionalism and can avoid incentives 

to "game the system" or to refrain from sharing knowledge and clinical experience. We believe 

that using competition to create economic winners and losers among physicians can only lead to 

reduced cooperation, collaboration, and information sharing that we all believe is essential to 

improving the practice of medicine. 

Finally, placing the focus on the individual practitioner detracts from the team approach to 

patient care that is the hallmark of many of the advances in medicine and surgery oflate. For 

example, in order for the heart team, which consists of the cardiothoracic surgeon, cardiologist, 

anesthesiologist, and advanced practice nurses and physician assistants (among others), to 

function at its highest level, there must be shared responsibility for patient care and patient 

outcomes. Similar relationships exist throughout medicine including the multidisciplinary team 

of heath care providers necessary to provide optimal care to patients with cancer and many other 

diseases. Assessing care quality at the institutional, regional, or national level allows the 

component parts of the health care team to share accountability, ensuring the patient receives the 

best care from the appropriate health care provider. 

STS believes that any new, alternative payment methodology should align incentives along 

specialty or disease process lines at the regional or national level. This type of payment system 

would foster and incentivize physicians to act as members of a profession and fulfill their 

professional responsibilities to collaborate and share knowledge and practices with their peers. 

There are several alternatives to current Medicare physician and hospital payment mechanisms 
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Chairman Pitts and Ranking Member Pallone 

Page 6 

which could advance these goals, including specialty-specific conversion factors for physician 

payment and global payments to hospitals and physicians for specified procedures such as 

isolated coronary bypass procedures. STS believes that the most powerful and reliable method to 

affect physician practice is to engage physicians in the collection of outcomes data on the 

services that they provide, and to provide meaningful, risk-adjusted feedback that allows them to 

compare these outcomes to those oftheir peers. We believe that the reimbursement system 

should promote physician practices that exemplifY the profession's responsibilities to not only 

improve the quality of the care that is given to patients but also to wisely allocate societal 

healthcare resources. We also believe that responsible professional organizations provide 

important database and educational resources that can provide the infrastructure to support the 

needed improvements in physician practice and resource utilization. 

5. How important will specialty specific clinical registries be for a process such as the one 

outlined in the Committee's legislative framework? Could such a registry serve as a' source 

of continual physician feedback and data as some have stated will be so important? 

The STS National Database is an example of an initiative that was designed precisely for the 

purposes described in this question. It is our strong beliefthat specialty-specific registries are the 

most appropriate source ofthis information and the best tool available to meet the goals of 

physician payment reform that achieves quality improvement. Peer pressure is an important 

factor in changing practice, and the closest medical peers are members of the same specialty. 

Most physicians identify directly with their specialty and also with their specialty or subspecialty societies. We also believe that these databases should be independently and randomly 

audited, as the STS database has been for several years, in order to provide credibility and 

comfort to the American public and to payors in the validity of the data. 

Any modernization of the physician payment system should ensure that individual medical 

specialties can-and have incentive to--control the growth rate of their services and payments 

by identifYing the most effective and appropriate treatment for the patient. At the very least, 

specialties should not be penalized if their quality and value improvement activities result in 

lower Medicare utilization and expenditures. As the STS National Database and registries of 

other specialties have demonstrated, feedback of credible, risk-adjusted outcomes data 

encourages physicians to change their practice patterns to achieve better outcomes, more 

efficient care delivery, and thereby, increased patient value. The following should be included in 

any Medicare physician payment reform initiatives: 

• Mandate and incentivize the development and utilization of specialty- specific clinical 

data registries; 

• Require the Centers for Medicare and Medicaid Services (CMS) and other payers to 

make administrative (cost and claims) data available to registries for use in their analyses 

so that resource utilization becomes an outcome variable to be assessed in the same 

manner as traditional clinical outcomes such as mortality or complication rates. The STS 

believes that the improvement in clinical outcomes without significantly reducing out- ofcontrol medical resource utilization is ultimately self-defeating; 

• Address barriers imposed by federal and state privacy regulations including, but not 

limited to the inability of our clinical registry to also collect administrative claims data 
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Chainnan Pitts and Ranking Member Pallone 

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and "outcomes" data contained in the SSDMF. Preventing the STS and any other 

legitimate specialty specific data registry from having access to infonnation as to the 

patient's final outcome (i.e. mortality) severely limits the power of clinical registries. Of 

course, the onus of protecting the privacy of patients should be required of the specialty 

societies and has been demonstrated for years by the STS National Database and its 

sound method of data encryption; 

• Allow physicians to share the savings generated by their quality improvement efforts and 

consider providing economic incentives and disincentives at higher levels than the 

individual physician or practice. 

• Utilize audited clinical registries and other resources to generate comparative 

effectiveness research; and 

• Consider significant changes to reimbursement systems for both hospitals and physicians 

that promote wise use of resources and improved clinical outcomes. 

STS urges Congress to consider quality incentive programs that encourage the coordination of 

Medicare claims data with existing clinical registries to enhance patient monitoring and 

physician performance, and improve quality. Without linking the administrative data collected 

by health plans and CMS with the clinical information reported by clinicians, patients cannot be 

effectively monitored. By using linked longitudinal registries, physicians can more broadly 

monitor patients for readmissions or care transitions. Similarly, longitudinal patient histories 

allow physicians to assess the long-tenn success of surgical or other medical interventions. The 

successful linking of the STS database with CMS administrative data in Virginia, for example, 

has led to a clinical/financial tool that brings quality improvement and cost containment to reality 

through a focus on reductions in costly complications and the redesign of care delivery models in 

order to promote high quality efficient care. 

A new STS public reporting initiative was launched in September 2010. By January, 2011 more 

than 20% of Adult Cardiac Surgery Database participants began to voluntarily report their heart 

bypass surgery perfonnance score to the public on www.sts.orgl.As ofJuly 2013, approximately 

43% of Database participants are voluntarily reporting their results for Coronary Artery Bypass 

Graft (CABG) and/or aortic valve replacement on the Consumer Reports and/or STS websites, 

and STS is universally regarded as the leading professional society in these activities. 

6. While primary care and some specialty groups have a long standing history of measure 

development and performance, others unfortunately lag behind. Do you believe that all 

provider groups adopting a system of quality measurement will be good for the provision of 

care in this country, and do you believe that provider specialties that are advanced in these 

areas might be able to help those who lag behind? 

As outlined previously, STS strongly believes that this process of collection of reliable outcomes 

data, central risk adjustment, and feedback is a strong motivator for practice improvement. We 

believe that these same principles apply across all areas of medicine. In some disciplines, the 

outcomes may be more difficult to precisely define, but we believe that outcomes measurement 

1 http://www.nejm.org/doi/pdf/10.1056/NEJMpl009423 
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Chairman Pitts and Ranking Member Pallone 

Page 8 

must be an integral part of quality improvement. STS and other surgical groups are recognized as 

leaders in this type of activity, but there are multiple other examples including collection of data 

on the treatment of cystic fibrosis and childhood cancers, to name a few. This approach is not 

new, but its expansion across all areas of medicine will require the appropriate incentives and 

support to overcome the important financial and motivational barriers that exist. 

STS as a professional society, and our individual members who have experience in working with 

the STS National Database are eager to help in the effort to proliferate best practices in clinical 

data collection and analysis to bring about a change in how care is provided in this country. We 

believe that we have the tools to ensure that the right patients receive the right care at the right 

time, every time. 

The Honorable John Shimkus 

1. Page 21 of the legislative framework released last week calls for the development of a 

"process by which physicians, medical societies, health care provider organizations, and 

other entities may propose" Alternative Payment Models for adoption and use in the 

Medicare program. Do you believe that model development from private payers and 

providers like those at Independent Health can lead to reforms that could benefit patients, 

providers, and taxpayers? 

While we appreciate that the current proposal, and the preponderance of our comments to date 

have addressed Medicare Fee For Service (FFS) payments, we feel strongly that the health care 

system should begin to move away from FFS and towards models of payment that promote 

provider collaboration in the treatment of a single patient. STS members are committed to the 

concept of team-care as exemplified by the heart team and cancer team. For example, STS 

worked to build the heart team concept into CMS's coverage with the evidence development 

decision for Transcatheter Aortic Valve Replacement therapy (T A VR). TA VR is covered for the 

treatment of severe aortic stenosis when furnished according to an FDA-approved indication. 

The T A VR National Coverage Decision requires that two cardiac surgeons have independently 

examined the patient and the patient is under the care of a heart team: a cohesive, 

multidisciplinary team of medical professionals that includes a cardiothoracic surgeon and a 

cardiologist. We have learned from cardiothoracic surgeons who practice in other countries that 

the heart team is so valued that the heart team actually receives payments for time spent 

consulting about the best treatment option for a given patient. While we may still be a few steps 

away from such an integrated payment system, STS members are committed to the practice of 

patient oriented care and STS is very supportive of the Alternative Payment Model proposals. 

The STS recognizes the inevitability and enormous value of the concept of a bundled payment 

initiative. 

However, we also recognize the need'to stabilize the FFS system before such wholesale reforms 

are able to take place inasmuch as some specialties are not able to accommodate a full transition, 

as yet. More importantly, however, the true value in the Committee's proposal is the 

commitment to the development of a robust clinical registry infrastructure that is critical to 

quality-focused reforms. Without such an infrastructure, physicians, who use evidence-based 

medicine as the basis for their daily practice, will have no ability to document their outcomes and 
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Chairman Pitts and Ranking Member Pallone 

Page 9 

compliance with evidence based medicine. We have focused our efforts at the specialty level, 

primarily because that reflects the organizational structure of much of medicine. It is not difficult 

to envision linkage of specialty level data along disease entity lines, much as the STS and ACC 

have linked their data in the ASCERT trial comparing the effectiveness of coronary bypass and 

percutaneous catheter based treatments for coronary artery disease. The critical issue is 

constructing a system and a professional ethic that emphasizes the collection of robust clinical 

and resource utilization data. 

The Honorable Cathy McMorris Rodgers 

1. Phase II of the House Energy and Commerce, health Subcommittee's proposal to repeal 

and replace the flawed Sustainable Growth (SGR) formula requests that providers submit 

"clinical practice improvement activities" to the HHS Secretary for approval. Clinical 

practice improvement activities are defined as activities that improve care delivery and, 

when effectively executed, are likely to result in improved health outcomes. 

It has come to my attention that other medical providers are already using clinical decision 

support tools (embedded with medical specialty society appropriateness criteria) as an 

example of a clinical improvement activity. These tools are both software and web based. 

One example is in the area of advanced diagnostic imaging. Clinical decision support tools, 

designed and used by radiologists, have demonstrated savings of health care dollars by 

reducing inappropriate utilization; reduction of patient exposure to unnecessary radiation; 

better care coordination; and shared decision making between the doctor and patient. 

In light ofthis doctor-initiated success, please comment on the merits and concerns about 

using such technology in other areas of medicine. 

Do you think it is feasible to consider this use of clinical decision support tools as one tool in 

the tool box of improving quality in healthcare? 

Clinical decision support tools, and the evidence-based development of such tools, are an 

invaluable asset to the practice of medicine. However, these tools should never be construed as 

usurping a physician's medical expertise and judgment. Yet it is the critical interplay between 

the physician's judgment and the various clinical support tools available to himlher that is 

emerging as the new construct for medical care. The STS believes that the various clinical 

support tools (e.g. the ACC/AHA Guidelines for Coronary Artery Bypass Graft surgery and 

Percutaneous Coronary Intervention [stentlangioplasty]), are meant to augment and not supplant 

the physicians' decision making expertise. 

The STS Risk Calculator is a publicly available, web-based tool that is used by surgeons to 

determine the best course of treatment, particularly when faced with a frail patient or one who 

has comorbid (i.e., co-existing) conditions. With millions of patients in its data repository, the 

STS Risk Calculator is so powerful that it is frequently cited in FDA approval and CMS 

coverage decisions as a criterion for the appropriate use of a treatment or therapy. For more 
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Chainnan Pitts and Ranking Member Pallone 

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infonnation about the STS Risk Calculator, please visit: http://www.sts.org/quality-researchpatient-safety/gualitv/risk-calculator-and-models 

The Society has developed several dozen risk-adjustment models for cardiothoracic surgery, all 

of which were derived using granular clinical data from thousands of patient records. STS has 

also developed sophisticated quality perfonnance measures in all three sub-specialties of 

cardiothoracic surgery (Adult Cardiac Surgery, Oeneral Thoracic Surgery, and Congenital 

Cardiac Surgery), and 32 ofthese measures have either been endorsed or are in the process of 

being considered for endorsement by the National Quality Forum. In 2007, STS began 

developing a family of composite perfonnance measures for the major procedures in CT 

Surgery, each one of which encompasses multiple domains of quality (e.g., mortality, morbidity, 

adherence to process measures). STS began this initiative with a composite measure for CABO, 

one of the most common cardiac surgical procedures. We have begun adding one new procedural 

composite measure each year (e.g., isolated aortic valve replacement, aortic valve replacement 

combined with CABO, mitral valve repair, etc.). The goal is develop a portfolio of these 

multidimensional composite measures that, in aggregate, will provide a broad perspective on the 

quality of a cardiac surgical practice." 

In 2012, the STS National Database fonned an Appropriateness Task Force. The goal ofthis task 

force is to map the variables in the STS National Database to specific guidelines 

recommendations and appropriate use criteria for coronary revascularization and CABO, as 

developed jointly by the American College of Cardiology, American Heart Association, and the 

Society of Thoracic Surgeons. Once this mapping is accomplished, it will be possible to 

immediately detennine from the patient's medical history and coronary artery 

symptoms/anatomy, as entered in the STS Database, whether the patient meets nationally 

accepted recommendations for surgery. This infonnation, in addition to patient-specific risk 

estimates from the STS National Database, will be extremely valuable elements oftruly 

informed consent and shared decision making. 

Tn the context ofthe Committee's proposal, STS believes that utilization of clinical decision 

support tools, or even steps towards adoption of clinical support tools, should be considered 

"Clinical Improvement Activities." We would suggest that such activities could be used to allow 

physicians to ramp up to full Phase II implementation, allowing the committee to reward 

providers who attempt to advance from Phase T more quickly. 

Clearly, encouraging providers to engage in certain Clinical Improvement Activities will help to 

set a level playing field among providers and specialties. This variable wiII be an important 

component of the program at its inception and provides a mechanism for policy-makers to signal 

recognition of innovations in health care delivery that they deem to be useful for future quality 

improvement. Like the quality measures, the list of clinical practice improvement activities can 

be updated regularly to promote growth and improvement. We support the proposal that 

physicians have the ability to choose from a menu of clinical practice improvement activities. 
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The Honorable Gus Bilirakis 

1. How much of these quality measures should be developed for the physician in general or 

should we have measures for specific diseases? How do we develop quality measures for 

rare diseases? These are hard to diagnose diseases with small populations. If we do develop 

metrics for specific conditions, how do we responsibly develop measurements for these 

conditions when research may be more limited? 

Risk adjustment for rare procedures is difficult because ofthe limited numbers of patients to 

develop risk adjusted models. However, in these situations, one can still collect clinical data 

including patient demographics and risk factors, as well as outcomes and processes and 

structures. These aggregate data can, when done on a national basis, contribute to assessing 

performance, but in particular add information that could be useful in improving treatment 

quality and value. 

Quality measures for the treatment ofrare diagnoses, therefore, are best developed from national 

aggregate data, as exemplified by the STS National Database. The STS National Database was 

established in 1989 as an initiative for quality assessment, improvement, and patient safety 

among cardiothoracic surgeons. The STS National Database has three components-Adult 

Cardiac, General Thoracic, and Congenital Heart Surgery and is organized around specific 

procedures within all three ofthose categories. The Database houses more than five million 

surgical records and gathers information from more than 90% of the approximately 1,100 groups 

that perform cardiac surgery in the United States. Anesthesiology participation is available 

within the Congenital Heart Surgery Database and will be added to the Adult Cardiac Surgery 

Database in 2013. In 2011, the Database expanded to include international participants; 

currently, Brazil, Israel, Turkey and Jordan have surgeons participating in the Database. STS 

also operates the STS/ACC TVT RegistryTM in ajoint effort with the American College of 

Cardiology (ACC)2. 

In general, the STS National Database provides: 

• a standardized, independently audited, nationally benchmarked too I for assessing the care 

of patients undergoing cardiothoracic operations; 

the opportunity to participate in national quality improvement efforts for cardiothoracic 

surgery that have an impact at the local, regional, and national levels; 

• a mechanism to target specific areas for clinical practice improvement; 

• the ability to investigate regional and national practice patterns in cardiothoracic surgery; 

and 

• the ability to conduct clinical and comparative effectiveness research using national 

aggregate data sets. 

2 The TVT Registry'· is a benchmarking tool developed to track patient safety and real-world outcomes related to 

the transcatheter aortic valve replacement (TAVR) procedure. Created by The Society of Thoracic Surgeons (STS) 

and the American College of Cardiology (ACC), the TVT Registry is designed to monitor the safety and efficacy of 

this new procedure for the treatment of aortic stenosis. https:llwww.ncdr.com/TVT/Home/Default.aspx 
174 


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Chairman Pitts and Ranking Member Pallone 

Page 12 

We feel that the best way to organize a clinical registry, particularly as it relates to cardiothoracic 

surgery, is to develop it around specific procedures. Doing so facilitates the risk adjustment and 

public reporting models highlighted above. To the extent that a procedural model is not 

accessible for other specialties or primary care providers, disease-specific or other models may 

be usefully employed. Disease and procedure-specific registries are the building blocks, and 

these registries can be linked together to provide more comprehensive assessments of physicians, 

groups, hospitals, or systems. 

The STS believes that it is the concept of a national data registry with continuous physician 

feedback that I) allowed us to realize enormous success in improving care within our own 

specialty, and 2) becomes a blueprint for the creation of similar national data registries that will 

positively affect clinical care in other medical disciplines. Instead offocusing on outcomes 

following coronary artery bypass, the primary care physician might be more interested in 

guidelines for the treatment of community-acquired pneumonia and more importantly with the 

continuous feedback that helps himlher assess clinical effectiveness with better outcomes and 

decreased utilization of precious medical resources. The medical oncologist might be able to, for 

the first time, have an objective yardstick to measure not only how the patients are doing as 

compared to national standards but also how he/she is performing relative to medical peers. 

We also believe that the physicians who best understand individual disease processes are in the 

best position to determine the most clinically relevant quality and outcomes measures, and we 

believe that external random audit processes will be essential for public and payor credibility. 

We recognize that there must be input and oversight from outside the specialty, but existing 

organizations, such as the National Quality Forum and the AMA PCPI that can provide this type 

of oversight. A measure that is appropriate for a cardiothoracic surgeon will surely not be 

appropriate for a primary care provider, but each medical and surgical specialty should determine 

clinically relevant outcomes to measure and should engage in the collection of outcomes data on 

important clinical diseases. 

2. How much input should patient groups have and what type of input into the process 

should they have when determining these measures? 

Input from patients is critical in the new era of health care delivery. The existence of national 

data registries and all ofthe clinical decision making tools is designed to facilitate the concept of 

shared decision making between the medical team and the patient. Significant improvements in 

quality outcomes will simply never be fully realized without meaningful patient participation in 

medical decisions. 

Clinical registries can and should track outcomes that are uniquely important to patients such as 

use ofmetrics for patient satisfaction, quality of life, and adequacy of communication with 

providers, etc. As outlined in question I, STS believes that a medical specialty should not be the 

sole developer of quality outcomes measures, and that patients and other interested parties should 

be able to participate in providing input on the types of outcomes to be measured. However, STS 

believes that each specialty or sub-specialty should be given the responsibility to receive input 

from patients and other interested groups and develop outcomes measures. 
175 


85440.126

July 12,2013 

Chairman Pitts and Ranking Member Pallone 

Page 13 

3. Should the system evolve to allow a direct feedback loop to the doctor? For example, the 

physician would know that they were paid X because they did or did not do Y to patient Z. 

Do we want that granular a system, or should the information and payment he done on a 

more aggregate level? 

The STS National Database and related initiatives (public reporting, physician feedback reports, 

risk calculator, etc.) are structured around measuring patient outcomes using NQF-endorsed 

outcomes measures that rely on data reporting and analysis of aggregate data. If cost data were 

available, we would suggest that it too is only relevant in the context of patient outcomes, in the 

aggregate. STS is not in favor of piecemeal incentives or penalties at the individual procedure, 

disease, patient, or physician level for the reasons outlined previously. 

4. Is it possihle to use physician quality measures to encourage patients to better follow 

doctor's plan to manage diseases? For example, a newly diagnosed diahetic getting a follow 

up call hy the doctor reminding them to check their blood sugar or reminding them to 

schedule an appointment with a nutritionist. Should these metrics be limited to what is 

done inside the physician's office? 

We believe that outcomes measures should be given more weight in a pay-for quality scenario, 

but that process and structural measures are a valid way to begin to measure quality. In fact, this 

is another area where we feel that specialties can begin to make strides towards Phase II 

implementation in a ramp-up scenario. We would endorse the development and utilization of 

process measures, an example of which would be receiving credit for executing a "follow-up" 

call to a newly diagnosed diabetic to remind him to check his blood sugar, etc. Ultimately, 

however, the system should move toward measurement oflongitudinal outcomes for the diabetic 

patient, such as Hemoglobin AIC levels, vision loss, limb loss, and ultimately survival. Structure 

and process measures can be used as a basis for registry reporting and physician feedback while 

data collection for the development of outcomes measures is underway. 

5. Should the quality measures be weighted? If there are 10 things that a doctor can do to 

increase their performance measure, should they be rated equally for payment bonuses or 

weighted to account for time or difficulty? 

We agree that measures should be weighted and propose the following breakdown, based on 

Donabedian's Triad of Structure, Process, and Outcome3

: 

• Outcomes: 50% 

• Process: 30% 

• Structural: 20% 

3 Donabedian A. Evaluating the quality of medical care. Milbank Mem Fund Q. 1966 Jul;44(3):Suppl:166·206. 
176 


85440.127

July 12,2013 

Chainnan Pitts and Ranking Member Pallone 

Page 14 

Member Requests for the Record 

The Honorable John D. DingelJ 

1. During the hearing, you agreed that Congress should look at the innovations and 

changes being made in the private sector when considering reforms to SGR. Would you 

please list some suggestions of what youfeel might be useful? 

Examples of such innovations include: 

1. Global payments for episodes of care such as an operative procedure with single 

payments being made for all physician and hospital services (Medicare demonstration 

project, payments by some private payors for congenital heart operations). 

2. The Virginia Cardiac Surgery Quality Initiative outlined above, and other regional 

initiatives including the Michigan-STS collaboration on adult cardiac surgery, and the 

Northern New England Cardiovascular Study Group. 

The Honorable Michael Burgess 

1. During the hearing, you mentioned the difficulty of obtaining some of the hospital data 

that CMS is releasing for developing performance metrics. You mentioned that asking 

CMS each time you request access to the data has become a bottleneck. Are there any other 

bottlenecks that you would identifY for the committee? 

As per above, since survival and resource utilization infonnation is such an important part of the 

outcomes for cardiothoracic surgery and the associated quality improvement efforts, we urge that 

steps be taken to insure that clinical registries have access to claims data from CMS (and, 

hopefully, other payors) and outcomes (death) data from the Social Security Administration or 

another, accessible source. It is imperative that the committees' bill address this foundational 

issue. As mentioned earlier, the existence of a national registry that collects enormous amounts 

of clinical data on every patient without ever knowing the patient's ultimate outcome (e.g., alive 

or dead) is a critical impediment to the relevancy of the data registry. Similarly, not knowing 

whether a given outcome can be achieved with far less utilization of medical resources appears 

to be in direct contradistinction to the intent of the proposed legislation. 

The ability to link clinical data with administrative data has opened up important new ways to 

assess the effectiveness of treatment options and offered new avenues for medical research. 

Clinical data yield sophisticated risk-adjustment assessments, while administrative data provide 

infonnation on long-tenn outcomes such as late mortality rate, readmission diagnoses, follow-up 

procedures, medication use, and total costs. STS has successfully linked its clinical data with 

CMS MEDPAR infonnation, on a project-by-project basis, to obtain longitudinal outcomes data 

for a wide array of cardiothoracic surgery operations. Linked data are particularly useful in 

conducting comparative effectiveness research (CER) and establishing appropriateness of care. 

However, the value of claims data without the context provided by clinical infonnation can be 

misconstrued and even dangerous to quality improvement because administrative data lack 

granularity in the clinical domains of diagnosis and therapy (including data about risk factors and 

severity of disease). 
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July 12,2013 

Chainnan Pitts and Ranking Member Pallone 

Page 15 

The longitudinal long-term outcomes infonnation derived from these administrative data 

sources, along with the Social Security Death Master File (SSDMF), helps physicians to provide 

infonnation to today's patients and families that can help them with shared decision making. 

Valid and reliable outcomes data give patients confidence in their medical interventions and 

demonstrate to patients and their families the durability and long-tenn benefits of medical 

procedures. It is important to note that STS, through its contracts with the Duke Clinical 

Research Institute, maintains the patient identifier data separately from the actual clinical and 

other demographic data, and the only patient level identified infonnation that ever leaves the 

database is simply that the patient has a record in the database. When the follow-up infonnation 

is returned from external entities, such as the SSDMF, it is linked back to the records in the deidentified database, but the flow of infonnation is only in this direction, The externally derived 

data are used to supplement the data in the individual record, but these clinical, patient level data 

never leaves the database except in de-identified fonn. 

Unfortunately, in November 2011, the Social Security Administration rescinded its policy of 

sharing state-reported death data as a part ofthe SSDMF. There are continuing efforts to further 

restrict access to the SSDMF so as to protect those listed in the file from identity theft. Balanced 

against these legitimate privacy concerns are the many advantages that SSDMF data can provide 

for quality improvement and medical research initiatives in the domains of comparative 

effectiveness research and outcomes assessment. Alternatively, the National Death Index could 

be supported with the appropriation of significantly greater resources to both lower the 

substantial cost of data (that makes is use not practical for most large clinical registries) and 

speed the availability of data from the current two year lag from death to availability of data 

documenting the death in the NDl. 

However, we caution, again, that publication of claims data, without the clinical context and 

robust demographic information essential to risk-adjustment could have extremely hannful 

effects. For that reason we oppose current efforts by the administration to provide general public 

access to Medicare Claims data and request significant revisions to S. 1180 and/or any similar 

legislation that is considered in the House. 

Additional barriers to implementation include the following: 

Healthcare providers are now being required to produce objective evidence of the quality, safety 

and value of care to a variety of healthcare stakeholders. These quality related efforts necessitate 

the collection, analysis and reporting of different clinical data for each payor. Meaningful data 

collection often relies on the ability to use individually identifying patient infonnation 

(particularly in analyses related to the value or sustainabiIity of treatment interventions) in a 

careful manner that protects patient privacy. Risk-adjusted data collected in this way reliably 

results in the generation of new knowledge. The current regulatory structure fails to recognize 

that data collection for quality improvement purposes (including the retention of Personal Health 

Information) and the generation of "new knowledge" pose no substantial risk to the patient. In 

the STS National Database environment, privacy risk is minimized since individual patient 

records exist in the clinical registry in a rigorously de-identified format. As the HIPAA Privacy 
178 


85440.129

July 12,2013 

Chainnan Pitts and Ranking Member Pallone 

Page 16 

Rule already addresses many of these patient privacy risks by imposing restrictions on how 

certain identifiable health infonnation is collected by health plans, healthcare clearinghouses, 

and health care providers ("covered entities" and their "business associates") and how it may be 

used and disclosed, it would appear superfluous and counterproductive to impose Common Rule 

consent requirements since compliance with HIP AA patient protections are already in place. 

In addition, STS requests that Congress instruct CMS to work with the Department of Health and 

Human Services Office for Human Research Protections (OHRP) and Office for Civil Rights 

(OCR) to establish appropriate standards for quality improvement (QI) activities that will 

adequately protect patients without unnecessarily burdening QI efforts. Until that guidance is 

made available, it is inevitable that significant variability in interpreting and applying the Privacy 

and Common Rules will persist. Specifically, we ask that OHRP issue guidance that the 

Common Rule does not apply to the collection and analysis of identifiable patient infonnation 

for quality assessment and improvement purposes where the entities collecting and analyzing the 

data (such as clinicians and a corresponding clinical data registry) are engaged in standard 

patient care and are in compliance with all applicable HIPAA requirements. Moreover, we ask 

that definitive language be included in federal guidance to allow for a clear differentiation 

between "human subjects research" and the processes related to the essential prospective 

analyses directed at advancing our national quality care objectives. In particular, the generation 

of new knowledge should be recognized as an expected and desired outcome of health care 

quality improvement projects; the processes related to the generation of such knowledge 

(through quality improvement initiatives that are part of healthcare operations) should therefore 

be exempt from a requirement for informed consent (on the basis that all HIPAA related 

regulations are adhered to in the course of clinical data collection and analysis). 

STS believes that the most effective mechanisms to improve practice are the collection of 

clinical data on every case, the submission to a central registry to allow risk adjustment, and the 

feedback of these risk-adjusted data to the individual physician and practice. Removal of barriers 

to this process and provision of incentives to encourage participation in this process is essential, 

including addressing patient privacy issues. We also feel that the practice of defensive medicine 

is, perhaps, the biggest challenge physicians face when working with patients to identity the best 

plan for treatment. Having clinical data that support practice guidelines and clinical decision 

making gives both providers and patients' confidence that the best care at the right time is being 

provided and received. Refonning the tort system to rely on these advances can only serve to 

promote provider buy-in to the provisions outlined above. The issue of overutilization will never 

be fully addressed without a significant and meaningful level oftort refonn. 
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85440.130

July 12,2013 

Chainnan Pitts and Ranking Member Pallone 

Page 17 

Thank you again for the opportunity to provide testimony and respond to the Committee's 

questions If you need additional infonnation, or if STS can be of any assistance, please contact 

Phil Bongiorno, STS Director of Government Relations, at pbongiorno@sts.orgor202-787-

1221. 

Sincerely, 

.1/) $ 

lj,l;JI·A.~ ~ f f ( /1 t . (j 

Jeffrey B. Rich, MD 

Past President 
180 


85440.131

PERSPECTIVE THE PARADOXICAL PROBLEM WITH MULTIPLE-IRe REVIEW 

cal improvement of protocols or 

consent forms.'!! On the contrary, 

this practice seems to pose a 

significant risk of diminishing 

studiesl ethical integrity. Fortunately, some ways of changing 

this system are being explored. 

Recently, the Office for Human 

Research Protections put out for 

public comment a proposal to 

receive direct authority to take 

action against IRBs - as distinct 

from the institutions conducting 

the research for noncompliance with regulations. 4 The intent is to encourage greater reliance on outside (and central) IRSs 

by assuring the individual institutions participating in multisite 

studies that they would not be 

blamed if an outside IRS were 

responsible for violations. 

Another approach to reducing 

the number of IRS reviews would 

be to have sponsors requlrc the 

use of a central IRS as a condition 

for participating in a study. Nothing in the existing U.S. regulations 

would prevent them from doing 

so. The Department of Veterans 

Affairs currently operates exactly 

such a system for a select group of 

studies. In an attempt to constrain 

the duplication of review efforts 

for international multisite studies, 

the European Union is taking a 

different approach: it now restricts 

each participating country to a 

Hsingle opinion" representing the 

ethics review for that country, 

"notwithstanding the number of 

Ethics Committees" involved." 

Anyone or a combination of 

these approaches may turn out to 

be satisfactory. But recognizing 

that the problem with multipleIRS review relates not merely to 

wasted time and effort but also 

to less-than-optimal protection of 

people who volunteer to participate in research should add urgency to our efforts to solve this 

problem. 

The views expressed in this article are 

those of the author and are not necessarily 

those of the U.S. Department of Health and 

Human Services or its operating division, 

the Office of the Assistant Secretary for 

Health. 

Disclosure forms provided by the author 

are available with the full text of this article at NEJM.org. 

Dr. Menikoff is the director of the Office for 

Human Research Protections, RockviHe, MD. 

This article {1O.10S6/NEJMp100S10l} was 

published on October 13, 2010, at NEJM.org. 

L National conference on alternative IRB 

models: optimizing human subject protection, 

November 19-21, 2006. (http://www.aamc 

.orgJresearchjirbreviewjirbconf06rpt.pdf.) 

2. NCI pOSition paper on PedClRB conflicts 

of interest. July 27, 2005. (http://www.hhs 

.govjohrp/requests/NClpos.htmL) 

3. Infectious Diseases Society of America. 

Grinding to a halt the effects of the increasmg regulatory burden on research and quality 

improvement efforts. (lin Infect Dis 2009; 

49:328·35. 

4. OffICe for Human Research Protections. 

Request for information and comments on 

IRB accountability. Fed Regist 2009;74: 

9578·83. (http://edocket.access.gpo.gov/2009j 

pdf/E9.4628.pdf) 

5, Directive 2001j20/EC of the European 

Parliament and oftne Council of 4 April 2001. 

On the approximation of the laws, regulations 

and administrative prOVisions of the memo 

ber states relating to the implementation 

of good clinical practice in the conduct of 

c:hnic:a! tnals on medicinal products for hu" 

man use. {http://www.eortc.be/ServicesjDocj 

dinicat-EU.directive.04.April.01.pdf.j 

COPYTlglrt © 2010 M~I\~,Ir"<Efl, Mcdjwl SO'lety. 

Public Release of Clinical Outcomes Data - Online CABG 

Report Cards 

Timothy G. Ferris, M.D., M.P.H., and David F. Torchiana, M.D. 

September 7, 2010, ConUnion (publisher of 

Consumer Reports) reported the re~ 

suIts of coronary-artery bypass 

grafting (CASG) procedures at 221 

U,S. cardiac surgery programs. 1 

The voluntary reporting of riskadjusted outcomes in approximately 20% of U.S. cardiac surgery 

programs is a watershed event in 

health care accountability. 

The reported ratings derive 

from a registry developed by the 

Society of Thoracic Surgeons (STS) 

iu 1989. More than 90% of the 

approximately 1100 U.S. cardiac 

surgery programs participate in 

the registry. Registry data are 

collected from patients' charts 

and include key outcomes such as 

complications and death, the severity of preoperative illness, co~ 

existing conditions, surgical technique, and medications. These 

data are maintained by the Duke 

Clinical Research Institute and 

are anaJyzed with the use of 

well-tested statistical methods. 

The data-collection and auditing 

methods, specifications of the 

measures, and statistical approaches have evolved over the 

course of two decades and reflect 

a substantial commitment by 

cardiac surgeons and their Jeadership.2,3 

For years, participants in the 

STS registry have been examining these data and using them 

to make improvements. What 

does the public now get to see? 

Each surgical program that has 

chosen to make its data public 

is assigned a rating of one, two, 

Of three stars. Stars are assigned 

on the basis of results on 11 performance measures (see table) that 

have been endorsed by the National Quality Forum. The rating depends on whether the risk-adjusted 

outcomes in a program fall beN ENGlJ MED 363:17 NEJM.ORG OCTOBER 21, 2010 1593 

The ~'ew England Journal of Medic inc 

Downloaded from nejm org on Jul) 12,2013. For personal usc only. No other llses without pcm1ission. 

Copyright if"' 2010 Massachusetts Medical Society All rights reserved. 
181 


85440.132

PERSPECTIVE PUBLIC RELEASE OF CLINICAL OUTCOMES DATA 

::, 'M_O~Q_\Ulietl!iY~_~~kS.!tI\l';;";i"t\i.H!.li~"rCi:i' •• !!tl'~Bl'!'!!'sll~1!ll 't,,' 

'§~ , ~'{'" /i \~ ~":;; ~ "" ~ "," £ \;r ~)J~~itt':~~ ~~4 "' '" ",_0 :~'" "", ~*' 

Measure Description 

Postoperative renal failure Percentage of patients (without preexisting renal failure) undergoing isolated CABG in whom 

postoperative renal failure developed or dialysis was required 

Surgical reexploration Percentage of patients undergoing isolated CABG who required a return to the operating 

room because ofb!eeding, tamponade, graft occlusion, or other cardiac reason 

AntipJatelet medication at discharge Percentage of patients undergoing isolated CABG who were receiving aspinn, safety-coated 

aspirin, or clopidogre! at discharge 

Beta-blockade at discharge Percentage of patients undergoing isolated CABG who were receiving beta-blockers at discharge 

Antilipid treatment at discharge Percentage of patients undergOing isolated CABG who were receiving a statin or other pharmacologic lipid-lowering regimen at discharge 

Risk-adjusted operative mortality after CABG Percentage of patients undergoing isolated CABG who died during the hospitalization in 

which the CABG was performed or within 30 days after the procedure 

Preoperative beta-blockade Percentage of patients undergoing isolated CABG who received beta-blockers within 

24 hours before surgery 

Prolonged intubation (ventilation) Percentage of patients undergOing isolated CABG (without preexisting intubation or tracheostomy) who required intubation for more than 24 hours 

Rate of deep sternal-wound infection Percentage of patients undergoing isolated CABG in whom a deep sternal-wound infection 

developed Within 30 days after the procedure 

Stroke or cerebrovascular accident Percentage of patients (without preexisting neurologic deficit) undergoing isolated CABG in 

whom a postoperative neurologic deficit developed that persisted for more than 24 hours 

CABG using an internal thoracic artery Percentage ofCABG performed using an internal thoracic artery 

1594 

low, are equal to, or exceed the 

average performance range. The 

performance thresholds are designed to ensure a 99% probability that outlier programs -

those rated significantly below 

or above the mean and therefore 

given one and three stars, respectively - are truly below or above 

average. With the use of this 

method, 23 to 27% of the programs have been identified as 

outliers over the past 3 years. In 

addition to the star rating for overall performance, consumers see 

the star rating and actual performance scores (on a scale from 0 to 

100) in four subcategories: 30-day 

survival ("patients have a 98% 

chance of surviving at least 30 

days after the procedure and of 

being discharged from the hospital"), complications ("patients have 

an 89% chance of avoiding all five 

of the major complications"), usc 

of appropriate medications ("pa' 

tients have a 90% chance of rcceiving all four of the recommended 

medications"), and surgical technique ("patients have a 98% 

chance of receiving at least one optimal surgical graft"). 

The move on the part of the 

STS to make results available to 

the public will certainly trigger a 

cascade of responses. Advocates 

of transparency will point to the 

shortcomings of thc ratings -

the voluntary and therefore selective participation of programs 

(50 of the programs that have 

chosen to report their data have 

received three stars, whereas only 

5 have received one star), the lack 

of long-term outcomes (e.g., 

lO-year survival, graft patency, 

and functional improvement), and 

the lack of physician-specific ratings. Expect such advocates to 

push for more. Nonparticipating 

cardiac surgery programs will 

come under pressure to allow the 

outcomes in their programs to 

be reported. Physicians in other 

surgical specialties that arc amcnable to this type of approach, 

such as orthopedics or vascular 

surgery, may be expected to follow suit. And this event will fuel 

the debate regarding the risks 

and benefits of public reporting, 

including the question of whether it assists patients in discriminating among sites of care. While 

these issues play out, several aspects of this release of ratings 

deserve attention. 

First, years of pressure from 

policymakers, health care purchasers, and patient-advocacy groups 

to provide greater accountability 

played a major role in bringing 

this publication to fruition. Public reporting of outcomes has 

widespread support, and cardiac 

surgeons have been among the 

principal targets of these efforts. 

The first statewide report card 

on cardiac surgical performance 

was mandated in New York in 

1989. Early experiences with pub, 

N ENGLJ MED 363:17 NEJIA.ORG OCTOBER 21, 2010 

The New England Journal of Medic inc 

Downloaded from nejm.org all July 12.2013. Forpersonat use only. :-Jo other uses v,:ithout pemlission. 

Copyright {\ 2010 Massachusetts Medical Society All rights reserved. 
182 


85440.133

PERSPECTIVE 

lic reporting of the outcomes of 

cardiac surgery spurred efforts by 

the STS and others to improve 

cardiac surgery.· Although some 

consumer advocates pushing for 

transparency may view this release 

as a glass four-fifths empty - given the selectivity and number of 

programs reporting - the external pressure has been critical in 

stimulating improvement efforts 

within the medical profession. 

Second. the publication of definitive analyses derived from clinical data can be a double-edged 

sword for providers. When performance reports are based on 

administrative data, physicians 

often justifiably argue that the 

data are flawed and the conclusions suspect. Tn contrast, with 

these new ratings, not only have 

the participants endorsed the 

methods, but they have volunteered to display performance 

results that carry the imprimatur of the physicians' specialty 

society. Experience with performance reporting in Massachusetts 

has shown that when the data 

and analyses are as good as possible, a public report of suboptimal performance requires a substantive public response: state 

Department of Public Health officials suspended a Massachusetts 

cardiac surgery program to conduct an external review, amidst 

substantial media attention, when 

the program was identified as a 

high-mortality outlier. 

Third, the process of moving 

clinical data from the STS registry into the public domain has 

been long, complex, and expensive. As a member-supported organization, the STS navigated 

treacherous waters to bring its 

members to the point of permitting the publication of their data. 

Some key decisions facilltated 

this process: the STS reported 

PUBLIC RELEASE OF CLINICAL OUTCOMES DATA 

group-level rather than physicianlevel data, rigorously validated its 

data-collection and risk-adjustment 

models, and selected a performance-classification system that 

maximized specificity. Such choices helped to mitigate physicians' 

biggest fear: the risk of misclassification. Moreover, cardiac surgery programs have been looking at these data for years, so 

there shouldn't be any surprises. 

The success that the STS has had 

in leading a nontrivial fraction of 

its members to agree to participate suggests that public reporting can be done in a way that 

doesn't alienate the profession. 

There is no question about 

the need for accountability on 

the part of health care providers 

or the central role of measurement in tbe improvement of health 

care. Nonetheless, questions re~ 

main about the role of public 

reporting in improving health 

care. Performance measurements 

audited by regulators are one alternative, especially in situations 

in which the information is too 

complex for patients to use in 

discriminating among care sites. 

Insofar as public reporting drives 

improvemellt of all outcomes, it 

benefits everyone; insofar as risk 

aversion leads to changes in the 

population receiving an indicated service, the net effect can be 

nil or even negative. 'j Given the 

heterogeneity in the delivery of 

medical services, it should come 

as no surprise that we have developed multiple methods for assessing performance and encouraging accountability. Regardless 

of which approach proves most 

beneficial to patients, public reporting will increasingly be a fact 

of life for physicians. 

By publishing ratings using 

the best available data, the STS 

has rcsponded to the public in a 

way that attempts to both inform 

patients and mitigate physicians' 

fears. We hope that tbe experience of the STS can be applied 

to other initiatives that are aimed 

at bringing performance data derived from clinical sources to the 

public, thereby reducing the time 

and expense of this process. For 

example, this experience may contain lessons for the Centers for 

Medicare and Medicaid Services 

as it prepares to handle the wave 

of clinical data it will receive 

through the Physician Quality Reporting Initiative and the "meaningful use" program for electronic 

health records. At least some of 

these data will almost certainly 

be publicly reported. The STS's 

success suggests that reporting 

can be done in a way that physicians will support. Whether the 

STS approach is an anomaly or a 

precedent that other specialty 

groups will emulate remains to 

be seen. 

Disclosure forms provided by the authors 

are avaiiabJe with the full text of this articleatNEJM.org. 

From the Massachusetts Genera.! Physicians 

Organization, Massachusetts General Hospital, Boston. 

This article (1O.lOS6/NEJMp1009423) was 

published on September 7, 20ID, at NEJM.org. 

1. COnSumer Reports home page. (http:// 

www.consumerreportshealth.org.) 

2. Shahian DM, Edwards FH, Ferraris VA, et 

al. Quality measurement in adult cardiac sur· 

gery: part 1 - conceptual framework and 

measure selection, Ann Thorac Surg 2007; 

83:Suppl:S3·S12. 

). O'Brien SM, Shahian OM, Delong fR, et 

at Quality measurement in adult cardiac surgery: part 2. - statistical considerations in 

composite measure scoring and provider ra.ting. Ann Thorac Surg 2007;83:Suppl:S13·S26. 

4. O'Connor GT, plume SK, Olmstead EM, 

et at. A regional intervention to improve the 

hospital mortality associated with coronary 

artery bypass graft surgery. JAMA 1996;275: 

841·6. 

5. Dranove 0, Kessler D, McClellan M, Sat· 

terthwaite M. Is more information better?The 

effects of "report cards" on health care pro· 

viders.) Pollt feon 2003;111:555·88. 

CopYright © 2010 M!ls~(l(:hu5ftts Mfd/wi Society 

N ENGLJ MED 363:17 NEJM,O~C: OCTOBER 21, 2010 1595 

The New England Journal of Medicine 

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Copyright «;> 2010 Massachusetts Medical Society. All rights reserved. 
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Report Overview 

General 

Report Overview 

STS 2010 Harvest1 Report 

TABLE OF CONTENTS 

Risk Adjustment Supplement 

STS Composite Quality Ratings and NQF Measures 

Public Dissemination of Quality Ratings 

STS Composite Quality Ratings 

NQF Measures 

Executive Summary 

Major Procedures Mortality 

Participant-Specific Cardiac Procedures 

Isolated Coronary Artery Bypass (CAB) 

CAB: On-pump Procedures 

CAB: Off-pump Procedures 

CAB: First Operations 

CAB: Reoperations 

Isolated Aortic Valve Replacement (AV Replace) 

Aortic Valve Replacement + CAB (AV Replace + CAB) 

Isolated Mitral Valve Replacement (MV Replace) 

Mitral Valve Replacement + CAB (MV Replace + CAB) 

Isolated Mitral Valve Repair (MV Repair) 

Mitral Valve Repair + CAB (MV Repair + CAB) 

Regional Outcomes Comparison 

other Procedures 

Appendix A: Participant-Specific Data Quality Summary 

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I. Introduction 

The Data Analyses of The Society of Thoracic Surgeons (STS) National Adult 

Cardiac Surgery Database are published following each quarterly database harvest 

and the report is provided to each eligible STS database participant. This report is an 

important quality improvement tool for participants, allowing them to compare their 

risk-adjusted performance with that of similar participants, participants in their 

geographic region and the entire body of STS database participants. 

This participant-specific report is unique to your organization. The data presented 

were collected during harvests from 2007, 2008 and 2009 of the STS Adult Cardiac 

Surgery Database at the Duke Clinical Research Institute (DCRI). The most recent 

procedure date included in this report is 12/31/2009. Data from previous harvests, 

when available, were also analyzed for the Executive Summary Section that 

presents longitudinal 1 O-year trends. Data in this report were subjected to identical 

data quality programs to make them consistent with the data specifications of the 

Adult Cardiac Surgery Database. 

This Report Overview is provided as background to help participants understand and 

interpret the results. Throughout this document, variable short names are used. 

Detailed information on the STS variables, including variable short names and 

clinical definitions can be found at the STS website - http://www.sts.org under the 

STS National Database tab. 

II. Report Organization 

Beginning in 2008, with the introduction of quarterly harvests, STS Adult 

Cardiac Surgery Database participants receive harvest reports with alternating 

content. This change allows distribution of analysis results to database participants 

in a timelier manner and is consistent with the STS policy to provide NQF Measure 

and Composite Quality Ratings results based on a full 12 months of data ending 

each June or December. The table below shows which sections will be provided after 

each of the four annual harvests: 

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Table 1. Quarterly Report Content 

Report Overview - General: Important information on the structure and content of 

the report, including risk-adjusted results. 

Report Overview - Risk-adjustment Supplement: Information about how 

participants can utilize STS risk-adjustment locally including instructions for 

calculating certain risk-adjustment statistics. 

Report Overview - STS Composite Quality Rating and NQF Measures 

Summary: Information about the calculation and interpretation of the STS 

Composite Quality Rating and the NQF measure results. (Harvest 1 and 3 only) 

STS Composite Quality Rating and NQF Measures: This section contains the 

participant STS Composite Quality Rating and the participant and STS overall results 

on the NQF Cardiac Surgery Quality Measures. (Harvest 1 and 3 only) 

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Executive Summary: This section displays overall database participant volume and 

procedure volume along with mortality and length of stay summaries. It displays 

annual distribution of all database procedures. 

Major Procedures Mortality: This section displays unadjusted and risk-adjusted 

mortality for the combined group of major procedures for which a risk-adjustment 

model exists: Isolated CAB, Isolated Valve Replacement, and Valve Replacement + 

CAB procedures. 

Participant-Specific Cardiac Procedures: The following sections display data for 

participant, a like-participant comparison group, and the overall STS for the following 

procedure classifications. 

Isolated Coronary Artery Bypass 

Isolated Aortic Valve Replacement 

Aortic Valve Replacement + CAB 

Isolated Mitral Valve Replacement 

Mitral Valve Replacement + CAB 

Isolated Mitral Valve Repair 

Mitral Valve Repair + CAB 

(CAB) 

(AV Replace) 

(AV Replace + CAB) 

(MV Replace) 

(MV Replace + CAB) 

(MV Repair) 

(MV Repair + CAB) 

CAB data are also stratified into the following SUbsets: On-Pump, Off-Pump, First 

Operation, Reoperation. 

Regional Outcomes Comparison: This section displays participant data alongside 

regional comparison data for selected outcomes. (Harvest 1 and 3 only) 

Other Procedures: This section displays only overall STS data for other cardiac 

procedures - includes AVR+MVR, Pulmonic Valve, Tricuspid Valve, LVA, VSD, ASD, 

SVR, and Aortic Aneurysm procedures, and Ventricular Assist Device. 

Appendix: Participant-Specific Data Quality Summary: This section provides a 

summary of your participating organization's specific data quality issues among CAB 

cases. (Harvest 1 and 3 only) 

III. How to Read this Report 

a. Patient Population 

Records were included in this report if they met the following criteria: 

• Patient age 18 or older 

• Valid procedure classification (see Section Ill.b. below) 

• Valid date of surgery 

Please note that individual records have been excluded from certain analyses for 

which they are irrelevant. Footnotes about these exclusions have been provided 

throughout the report and a summary table of the exclusions has been provided 

in Section Ill.d. 

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The time window of procedures presented in this report varies depending on the 

section of the report: 

STS Composite Quality Rating 

and NQF Measures 

(Harvest 1 and 3 only) 

Executive Summary 

Major Procedures Mortality Summary 

Participant-Specific Cardiac Procedures 

Regional Outcomes Comparison 

(Harvest 1 and 3 only) 

Other Procedures 

NOTE: 

CAB: Last 12 months 

Valve, Valve + CAB: Last 60 months 

Last 10 calendar years 

Last 3 calendar years 

Participant: 

Like Group: 

STS: 

Participant: 

Region: 

Last 3 calendar years 

Last calendar year 

Last calendar year 

Last calendar year 

Last calendar year 

Last calendar year 

--N-ot all participants have submitted data for the entire time 

period presented in this report. 

b. Procedure Classification 

The majority of this report represents the following seven procedure 

classifications: 

Isolated Coronary Artery Bypass 

Isolated Aortic Valve Replacement 

Aortic Valve Replacement + CAB 

Isolated Mitral Valve Replacement 

Mitral Valve Replacement + CAB 

Isolated Mitral Valve Repair 

Mitral Valve Repair + CAB 

(CAB) 

(AV Replace) 

(AV Replace + CAB) 

(MV Replace) 

(MV Replace + CAB) 

(MV Repair) 

(MV Repair + CAB) 

Records were classified as one of the above if there were no other cardiac or 

non-cardiac procedures performed at the same time [exception: OCarACD 

(arrhythmia correction devices) was not a classification exclusion criterion]. See 

Table 12 for more details. 

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Lower volume cardiac procedures are summarized for the STS as a whole in the 

Other Procedures section. These include: 

Aortic Valve + Mitral Valve Replacement 

Pulmonic Valve 

Tricuspid Valve 

Left Ventricular Aneurysm 

Ventricular Septal Defect 

Atrial Septal Defect 

Surgical Ventricular Restoration 

Aortic Aneurysm: Ascending Aorta, Aortic Arch, Descending Aorta, and 

Thoracoabdominal Aorta 

Ventricular Assist Device (VAD) 

Except for Aortic Valve + Mitral Valve Replacement, these procedures are 

considered independently. It is possible, for instance, for a record to contain both 

a Pulmonic Valve procedure and a Tricuspid Valve procedure; that record would 

be counted in both categories. 

c. Reporting Levels 

Participant: Your Participant ID is used as the grouping identifier for reporting. 

The definition of participant varies among data contributors. A participant may be 

surgeon(s) from a single hospital or across multiple hospitals. 

Like Group: The Like Group is a comparison group of STS participants that are 

most similar to the report participant with respect to annual site case volume and 

presence or absence of a surgical residency program. Like Groups are 

determined annually following Harvest 1. For each participant two Like Groups 

are created. The CAB Like Group is based on the participant's CAB procedure 

volume, and the Valve Like Group is based on the participant's valve procedure 

volume. The CAB Like Group is displayed for the Major Procedures Mortality 

summary and the CAB portion of the Participant-Specific Cardiac Procedures 

section. The Valve Like Group is displayed for the remainder of the ParticipantSpecific Cardiac Procedures section. See the Table below for details on Like 

Group determination. Annualized procedure volume is an average based on the 

past 3 years of data. The groups are structured such that an adequate number of 

participants/cases are assigned to each one. The smallest CABG like group 

(number of cases) contains 13,076 cases. The smallest CABG like group 

(number of participants) contains 12 participants. The smallest Valve like group 

(number of cases) contains 2,367 cases. The smallest Valve like group (number 

of participants) contains 28 participants. 

Infrequently, risk-adjusted results cannot be calculated for a Like 

Group due to small sample size and/or zero outcome events. In 

such instances, a '-' will be presented in place of a statistic. 

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Table 2. Definition of Like Group 

Annualized Procedure Surgical Residency' 

Volume 

• L-____________ ~~~~~ ________ _i~~ ____________ ~ 

A participant is considered to have a surgical residency program if at least one of the 

hospitals for which data were submitted has a known residency program. Residency 

programs are identified via annual review of the list of accredited programs specializing in 

Thoracic Surgery of the American Council for Graduate Medical Education (ACGME), a 

private, non-profit council that evaluates and accredits medical residency programs in the 

United States. 

Participant's Region: Participant data are compared to regional benchmark 

data in the Regional Outcomes Comparison section. For most participants the 

region is the state or province in which they are located. However, for states and 

provinces that do not contain enough participants to provide a meaningful 

comparison group, region is defined according to the following table (derived 

from the Dartmouth Atlas of Health Care). 

Please refer to the map in the Regional Outcomes Comparison section (Harvest 

1 and 3 only) to identify your region. 

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Table 3. Regions 

Realon States I Provinces 

New England Connecticut, Massachusetts, Maine, New Hampshire, Rhode Island, 

Vermont 

Middle A~antic New Jersey, New York, Pennsylvania 

South Atlantic Delaware, District of Columbia, Florida, Georgia, Maryland, North Carolina, 

South Carolina, Virginia, West Virginia 

Great Lakes Illinois, Indiana, Michigan, Ohio, Wisconsin 

East South Central Alabama, Kentucky, Mississippi, Tennessee 

Great Plains Iowa, Kansas, Minnesota, Missouri, Nebraska, North Dakota, South Dakota 

West South Central Arkansas, Louisiana, Oklahoma, Texas 

Mountain Arizona, Colorado, Idaho, Montana, Nevada, New Mexico, Utah, Wyoming 

Pacific Alaska, California, Hawaii, Oregon, Washington 

Canada Alberta, British Columbia, Manitoba, Nova Scotia, New Brunswick, Ontario, 

Quebec 

d. Data Handling 

Missing data 

For dichotomous and categorical variables, percentages are calculated using all 

records, unless otherwise specified (See Inclusion/Exclusion Criteria below for 

specific restrictions). For continuous variables, missing data are not calculated 

into summary results or into mean and median calculations. The Case Count 

Report provided along with each harvest report indicates the number of cases 

used for each result in the report. 

Zero values 

For the analysis of Perfusion Time (PerfusTm) and Cross Clamp Time 

(XClampTm), zeros are not included in the calculation of means and medians. 

Outlier Values 

Values that have been determined to be aggregate outliers (see the ParticipantSpecific Data Quality Summary for more information on outliers - Harvest 1 and 

3 only) are bolded within this report. 

Inclusion/Exclusion Criteria 

In nearly all cases, results represent the entire group of cases eligible for that 

section of the report (e.g. all isolated CAB procedures in the isolated CAB section 

of the report). However, certain variables must be analyzed using a restricted 

population. An example of such a variable is Discharge Location (DisLoctn). 

Analysis of this variable should only include those patients discharged from the 

hospital alive. Footnotes about such case selection restrictions appear in the 

report. Table 4 below contains a summary of these restrictions. 

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Table 4. Analysis Restrictions' 

Data element Inclusion/exclusion criteria 

HemodYnamics & Catheterization 

EF<40 Patients with measured EF 

Pulmonary Hypertension Patients with measured PA mean pressure 

Comorbidities 

Previous PCI Stent Patients with previous PCI 

Preoperative and Discharge Medications 

Preop: ADP Inhibitors Discontinuation Patients on ADP Inhibitors within 5 days 

All Medications - eligible Excludes contraindicated/not indicated 

Operative Information , 

Vein Harvest Technique Patients with at least 1 harvested vein 

Intemal Mammary Artery Used Excludes patients with prior CAB surgery 

Postoperative Information: 

Initial Ventilation <6 Hours Excludes patients extubated in OR 

Additional Ventilation Hours Patients reintubated 

AdditionallCU hours Patients readmitted to the ICU 

Complication 

Leg infection Excludes patients with zero vein grafts 

Arm infection Excludes patients with zero vein grafts 

Renal Failure Excludes patients with preop dialysis 

Atrial Fibrillation Excludes patients with preop AFib 

Discharge & Readmission 

Discharge Location Excludes in-hospital mortalities 

Discharge Medications Excludes in-hospital mortalities 

Readmission Excludes in-hospital mortalities 

Smoking Cessation Counseling Excludes in-hospital mortalities and N/A 

responses 

Cardiac Rehabilitation Referral Excludes in-hospital mortalities and N/A 

responses 

• See Table 2 of the STS Composite Quality Rating and NQF Measures Report Overview 

(Harvest 1 and 3 only) for specifics on inclusion/exclusion criteria for the STS Composite 

Quality Rating and NQF Measures sections of the report. 

Data Warehouse Edits 

When data arrive at the data warehouse, they are checked carefully for logical 

inconsistencies and parent/child variable relationship violations. Any 

inconsistencies or violations are communicated to participants in the detailed 

Data Quality Report that is generated automatically following each harvest file 

submission. If the data inconsistencies are not changed by the participant prior to 

harvest close, the data warehouse performs consistency edits and/or parent/child 

edits on the data in order for them to be analyzable. Participants are informed of 

such edits to their data in the Data Quality Report. 

A complete list of data edits performed at the data warehouse is available at the 

STS website - http://www.sts.org - under the STS National Database tab. 

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NOTE: Commercial software vendors are encouraged, but not required, to 

incorporate edit checks for such data inconsistencies into their STS-certified 

software packages to reduce the number of data edits that must take place at the 

data warehouse. 

e. Reported Variables 

Because we have found that lengthy clinical outcomes reports are hard to read, 

this report does not contain every variable collected as part of the STS Adult 

Cardiac Surgery Database. Members of the STS and the DCRI carefully select 

the variables for inclusion in the report. Feedback from the participant sites is 

vital to this decision-making process. 

The variables and data definitions used in this report are from Versions 2.35, 

2.41, 2.52.1, and 2.61 Adult Cardiac Database Specifications. 

PROCEDURE TIME WINDOW 

1/1999 - 12/2001 

1/2002 - 6/2002 

7/2002 - 12/2003 

112004 - 12/2004 

112005 - 6/2007 

7/2007 - 12/2007 

112008 - 9/2009 

Calculated Variables 

ALLOWABLE DATA VERSION(S) 

2.35 

2.35,2.41 

2.41 

2.41, 2.52.1 

2.52.1 

2.52.1, 2.61 

2.61 

Several report variables, such as Obesity, and Observed Operative Mortality are 

calculated using the STS variables and data definitions. Please refer to Table 13 

at the back of this section of the Report Overview for a complete list of calculated 

variables. 

f. Data Presentation 

The tables and figures in this report primarily show variable means, medians, 

25th and 75th percentiles, or percents. 

Mean: A measure of central tendency that is computed by adding up all 

the individual values in the group and dividing by the number of the 

values in the group. 

Median: A measure of central tendency that is the value under and over 

which 50% of the individual values lie. 

25th percentile: The value under which 25% of the individual values lie. 

75th percentile: The value under which 75% of the individual values lie. 

The risk-adjusted outcomes in this report are presented as OlE ratios, estimated 

Odds Ratios, and risk-adjusted rates (see Section IV below for details). Each of 

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these is presented with 95% confidence intervals (CI) - the range of values in 

which the analysts are 95% confident that the true value for the underlying 

population falls. 

Indentation 

Throughout the report, indentation indicates that indented lines are related to the 

un-indented lines in a hierarchical manner. Results on indented lines are 

generally not based upon a smaller denominator than the un-indented lines 

unless there is an explicit footnote to that effect. For instance for Isolated CABs 

in the Participant-Specific Cardiac Procedures report section, 'Previous PCI' is an 

un-indented line and the timing of the previous PCI (S 6hours prior to surgery, >6 

hours prior to surgery) is on subsequent indented line(s). The denominator for 

both of these items is the same - the total number of isolated CAB procedures. 

Dashes 

A value of '-' indicates that there were no occurrences of a value for that variable 

in the data for that time period. 

g. Comparisons to Like Group, Region and Overall STS 

While we encourage participants to focus on how their results compare with 

those from their region, their like group, and national STS outcomes, a few words 

of caution are needed: 

• There is a wide range in the volume of procedures submitted among 

participants. Those participants with low volume must be aware that their 

measured results are less stable as compared with those from a high volume 

participant (indicated by the wide confidence intervals surrounding low 

volume estimates). 

• If an individual participant's results in a given region vary considerably from 

their peers, they can potentially alter that region's results. For example, if a 

participant erroneously reported their CAB patients all have a post-op stroke, 

then that region's aggregate stroke rate may be falsely elevated. Because of 

its size, the more stable benchmark will always be the overall STS results. 

• Finally, it must be recalled that the current STS data have not been fully 

validated. While we believe that participants generally report accurate 

results, participants may vary in the degree to which they identify certain 

events (e.g. postoperative complications and 30-day mortality). 

IV. Risk-Adjusted Results: Overview 

a. What is risk adjustment? 

The purpose of risk adjustment is to allow STS database participants to 

compare their performance with other participants (e.g. overall STS, like 

participants, region or state). By accounting for and controlling patient risk 

factors that are present prior to surgery, risk adjustment "levels the playing 

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field" as best as possible. Unadjusted event rates are not used for such 

comparisons because they are influenced by patient case-mix and disease 

severity, which vary from participant to participant. Comparing unadjusted 

event rates would unfairly penalize participants that perform operations on 

higher-risk patients. Risk adjustment more accurately represents a 

participant's performance relative to that of a reference group presented with 

the same patient population. Importantly, as these are indirectly standardized 

rates, it is often not appropriate to directly compare the risk-adjusted mortality 

rates of two specific participants unless their patient populations are relatively 

similar (Shahian OM, Normand Sol T. Comparison of "risk-adjusted" hospital 

outcomes. Circulation. 2008 Apr 15;117(15):1955-63). 

b. STS risk-adiustment models 

In conjunction with the 2.61 data version update, the STS Quality Measurement 

Taskforce substantially revised all existing risk models and introduced several 

new ones. The models were developed and tested using all cases from 1/1/2002-

12/31/2006. These new models are referred to as the 2008 STS models. The 

previous STS risk models distributed with data version 2.52.1 are referred to as 

the 2004 STS models. Work is well underway on a set of manuscripts that will 

provide the details of model development process and the models themselves. 

Beginning with cases performed in 2008 all risk-adjustment analyses for the STS 

Adult Cardiac Surgery Database report will be performed with the 2008 STS 

models. With the exception of STS Composite Quality Rating analyses, cases 

performed prior to 1/1/2008 will be analyzed with the previous set of models. See 

below for more details about the 2008 risk models. 

NOTE: 

• Risk-adjusted results will only be provided for a time period of 6 or 

more months of data due to concerns for small sample size. 

Newly introduced models for valve and valve + CAB combinations 

will not be added into the report until at least 2009. 

The STS currently has 3 risk models: CAB, Valve, and Valve + CAB. The models 

apply to 7 specific surgical procedure classifications: 

Table 5. Surgical procedure classifications for STS risk models 

CAB model '.' 

1. Isolated Coronary Artery Bypass (CAB Only) 

Valve mOdel '. 

2. Isolated Aortic Valve Replacement (AV Replace) 

3. Isolated Mitral Valve Replacement (MV Replace) 

4. Isolated Mitral Valve Repair (MV Repair) 

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ValvetCAB model , 

5. Aortic Valve Replacement + CAB (AV Replace + CAB) 

6. Mitral Valve Replacement + CAB (MV Replace + CAB) 

7. Mitral Valve Repair + CAB (MV Repair + CAB) 

See Table 12 below for detailed definitions of these procedure classifications. 

c. Model endpoints 

Table 6 contains a complete listing and definition of all model outcomes. The 

STS is pleased to now have mortality and morbidity models for all of the 

procedure classifications in Table 5 above. Previously, morbidity endpoints were 

only modeled for the isolated CAB population. 

NOTE: Newly introduced models for valve and valve + CAB combinations 

will not be added into the report until at least 2009. 

Table 6. Definition of STS Risk Model Outcomes 

Endpoint Del!cription .,,~.} . ,', 

STS v2.61 Sequence number 3050 (MtOpD): 

., 

Operative mortality includes both (1) ali deaths occurring during the hospitalization 

Operative Mortality in which the operation was performed, even if after 30 days; and (2) those deaths 

occurring after discharge from the hospital, but within 30 days of the procedure 

unless the cause of death is clearly unrelated to the operation. 

STS v2.61 Sequence number 2830 (CNStrokP): 

Permanent Stroke Postoperative stroke (i.e., any confirmed neurological deficit of abrupt onset caused 

by a disturbance in cerebral blood supply) that did not resolve within 24 hours. 

STS v2.61 Sequence number 2890 (CRenFail): 

Acute or worsening renal failure resulting in one or more of the following: 

Renal Failure 1. Increase of serum creatinine to > 2.0. and 2x most recent preoperative creatinine 

level. 

2. A new requirement for dialysis postoperatively. 

Prolonged STS v2.61 Sequence number 2860 (CPVntlng): 

Ventilation Prolonged pulmonary ventilator> 24 hours. 

> 24 hours Include (but not limited to) causes such as ARDS, pulmonary edema, andlor any 

patient requiring mechanical ventilation> 24 hours postoperatively. 

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Endpoint "c. Dellcripijon . .. 

STS v2.61 Sequence number 2780 (CIStDeep): 

Deep sternal infection, within 30 days postoperatively, involving muscle, bone, 

Deep Sternal and/or mediastinum REQUIRING OPERATIVE INTERVENTION. 

Must have ALL of the following conditions: Wound Infection 1. Wound opened with excision of tissue (I&D) or re-exploration of mediastinum 

2. Positive culture 

3. Treatment with antibiotics. 

STS v2.61 Sequence numbers 2720 (COp ReBid), 2730 (COpReVlv), 2740 

Reoperation (COpReGft), 2750 (COpReOth), 2760 (COpReNon): 

For any reason Reoperation for bleeding/tamponade, valvular dysfunction, graft occlusion, other 

cardiac reason, or non-cardiac reason 

Major Morbidity or A composite endpoint defined as any of the outcomes listed in the first six rows of 

Operative Mortality this table. 

Short Stay: 

Discharged alive and within 5 days of surgery PLOS < 6 days· 

Long Stay: Failure to be discharged within 14 days of surgery PLOS >14 days 

'NOTE: The definition of the short length-of-stay endpoint differs from previous versions of 

the STS risk model. In the new definition, patients must be discharged alive in order to 

receive credit for a PLOS < 6 days. 

d. Model patient populations 

The models can be applied to all adult patients who fall into one of the 7 surgical 

procedure populations described above in Table 5 above, except as follows: 

The models will only calculate a predicted risk value for adult patients age 

1 B to 110 years. 

The models will only calculate a predicted risk value for those patients for 

whom both age and gender are known. 

The models for renal failure will NOT calculate a predicted risk value for 

any patients who are on dialysis preoperatively. 

e. Missing data handling for models 

It is important to understand how missing data values are handled when 

the STS risk-adjustment models are applied to patients with incomplete 

data. With the exception of age and gender, missing data values are imputed by 

assigning a likely substitute value. The algorithm used for missing data 

imputation is described below: 

Required variables: Age and gender are required variables for all models. If 

either is missing, no value for predicted risk will be calculated. 

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Categorical variables: Missing data are generally assumed to have the lowest 

risk category. For example, if diabetes was not coded, it would be assumed to be 

"No"; if procedure priority were not coded, the procedure would be assumed to 

be "Elective." In most cases, the lowest risk category is also the most frequent. 

Continuous variables: Table 7 shows the values assigned to missing data for 

continuous model variables. 

Table 7. Imputation of Missing Continuous Variables 

Model Variable Model Imputation Information 

Body Surface Area If gender is "Male" set BSA = 2.00m2 

(BSA) If gender is "Female" set BSA = 1.75m2 

Ejection Fraction (EF) CAB Model 

If CHF is no or missing, set EF = 50% 

If CHF is yes and gender is Male, set EF = 35% 

If CHF is yes and gender is Female, set EF = 45% 

Valve Model 

Set EF = 50% 

Valve+CAB Model 

If CHF is yes and gender is Male, set EF = 40% 

Otherwise, set EF = 50% 

Last Preop Creatinine Set CreatLst = 1.0 

f. Discrimination and calibration of risk-adjustment models 

At the time the 2008 STS risk models were developed, each model was tested to 

ensure there was a close fit between the model and the data. Outcomes may 

have changed since the time of model development, therefore it is important to 

assess whether the models continue to perform well on each subsequent 

harvest. Two important aspects of model performance that are assessed on a 

continual (per harvest) basis are calibration and discrimination. 

Calibration: A model is said to be well calibrated if there is a close match 

between the observed number of deaths and the number of deaths predicted by 

the model. Typically, calibration is assessed on the population of interest overall, 

as well as in several subgroups. For example, it is common to compare observed 

vs. predicted event rates within 10 subgroups based on dedles of predicted risk. 

In the past, we have found that risk-adjustment models that were developed 

several years ago are not well calibrated when applied to a contemporary data 

set. In general, older models tend to over-estimate risk relative to contemporary 

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experience because outcomes have improved over time. To make the models 

more accurate, each model is re-calibrated each harvest. This recalibration 

ensures that the total number of "events" predicted by the model will exactly 

match the actual number of events that was observed in the data. After this initial 

recalibration, calibration is then assessed graphically by plotting and comparing 

observed vs. predicted event rates within several patient subgroups. Because of 

the large number of models and sub populations, these graphs are not provided 

in the report overview but are available on request. 

Discrimination: A model is said to have good discrimination if it is able to 

distinguish patients who are likely to have an event from those who are not likely 

to have an event. A commonly used measure of discrimination is the C statistic 

(also known as the area under the ROC curve). The C statistic represents the 

probability that a patient who experienced an event (e.g. died) had a higher 

predicted risk compared to a patient who did not experiencE!:'theevent. The C 

statistic generally ranges from 0.5 to 1.0 with 0.5 representing<i\o1:!iscrimination 

(i.e. a coin flip) and 1.0 representing perfect discrimioation. C~tatistics for all 

STS models for the time period included in this an:f'Presented in the Table 

8 below. 

Table 8. STS Model C Statistics (Discril)1inat:lbn)- 2009 Harvest 3 

2004 STS Models - January 1,2006 - December 31,2007 

2008 STS Models - January 1, 200~£l: December 31, 2009 

"''i004 STS Models '.' 2008 STSModeis 

0.801 0.806 

0.701 0.708 

0.748 0.774 

0.746 0.755 

0.657 0.686 

0.653 0.659 

0.717 0.725 

0.710 0.719 

0.760 0.767 

Isolated Valve 

Model Endpoint 2004 STS Models 2008 STS Models 

Operative Mortality 0.764 0.783 

Permanent Stroke NA 0.684 

Renal Failure NA 0.752 

Prolonged Ventilation NA 0.749 

Deep Sternal Wound Infection NA 0.659 

Reoperation for any reason NA 0.646 

Major Morbidity or Operative Mortality NA 0.718 

Short Length of Stay NA 0.744 

Prolonged Length of Stay NA 0.769 

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Valve + CAB 

Model EndPOiot 2004 815 Models 200(1 STS ModelS 

Operative Mortality 0.737 0.748 

Permanent Stroke NA 0.635 

Renal Failure NA 0.715 

ProlonQed Ventilation NA 0.716 

Deep Sternal Wound Infection NA 0.704 

Reoperation for any reason NA 0.627 

Major Morbidity or Operative Mortality NA 0.699 

Short Length of Stay NA 0.729 

ProlonQed LenQth of Stay NA 0.727 

q. Predicted risk values 

After information has been entered on a given case, theSr& riSkrnodel (either 

from your STS software vendor or internal system) wiltproviCie a risk percentage 

for each of the outcomes. The risk percentage is tM"estmpated percent chance of 

the outcome for a patient with the indicated risk f~t9rs. please note that 

depending upon your vendor software, a riskper~(Jtage for each outcome might 

be calculated as each question is answered; the,refqre, the most reliable risk 

percentage will appear only after all availabl~ dat~ have been entered. 

Note on interpretation of values: 

The inherent limitations of statistical rjsk-adjustment models should be kept in 

mind when interpreting risk percentage,.values for an individual patient. Risk 

adjustment attempts to tak.~il"lf6 account as many of the patient's risk factors as 

possible. However, there~resomerare or difficult to measure factors that are not 

included in the STS risk-:-a"Cljt:(stment models and which may increase or decrease 

a patient's risk of an adverse outcome. 

As with any st~ti~.tic~l-E?stimates, the risk percentage values should be 

supplemented by loe professional judgment of the patient's healthcare provider, 

particularly their cardiac surgeon. 

Impact of new'models on predicted risk values 

The STS is committed to updating its risk models approximately once every 3 

years. The risk profiles of cardiothoracic surgery patients have been consistently 

worsening through time at the same time that outcomes of cardiothoracic surgery 

have improved through time. Therefore, it is normal and expected that predicted 

risk values calculated with the new model will be on average lower than those 

calculated with the old model. 

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h. Risk-adjusted summary statistics 

The STS report uses two types of summary statistics to present risk-adjusted 

results: i) observed to expected (OlE) Ratios; and Ii) model-based Odds Ratio 

(OR) estimates. Because each of these statistics has advantages, the STS has 

decided to provide both in the report. As discussed in the interpretation manual 

(next section of this report overview), the interpretations of the Odds Ratio and 

OlE Ratio are similar. It is the method of estimating these quantities that differs. 

OlE Ratio 

The OlE Ratio is the ratio of a participant's number (or percent) of observed 

outcome events relative to the number (or percent) of outcome events that is 

expected (predicted) by the STS risk-adjustment model, based on the 

participant's case mix. See Section IV.d. for information on how to interpret the 

OlE Ratio. 

Estimated Odds Ratio 

The other main summary statistic, the estimated Odds Ratio, is obtained by fitting 

a set of hierarchical logistic regression models to the harvested data. These 

models are estimated every six months in conjunction with generating the report. 

They are only used for the current report and are not used subsequently. Unlike 

the "STS risk-adjustment models" described in Section IV.b., these models 

cannot be incorporated into your STS certified software. 

In a hierarchical logistic regression model, the probability that a patient 

experiences an adverse event is assumed to depend on both patient 

characteristics (e.g. patient risk factors) as well as the participant (e.g. 

performance). The Odds Ratio measures the effect that the participant has on a 

patient's probability of experiencing an adverse event. The interpretation of the 

Odds Ratio is similar to that of the OlE Ratio in that smaller Odds Ratios imply 

better performance. See Section IV.d. for information on how to interpret the 

Odds Ratio. 

Comparison of OlE Ratios and Odds Ratios 

Because each of these statistics has its advantages, the STS has decided to 

provide both in the report. The benefit of OlE Ratios is that they are familiar to 

many surgeons and are simple to compute using an STS-certified software 

package. The hierarchical models used to create the estimated Odds Ratios do 

not provide a formula that can be incorporated into a software package. The 

main benefit of Odds Ratios obtained from hierarchical models is that they 

provide a more reliable estimate of performance for hospitals with a small 

number of patients. 

Because hierarchical models borrow information across participants when 

estimating performance for each individual participant, risk-adjusted statistics are 

closer to the overall STS average than under the non-hierarchical approach. For 

example, although a participant might have zero events this year, the best 

estimate of long-run performance is not 0%, but something higher and closer to 

the overall STS average. How much higher depends on sample size. If a 

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participant has a very large sample size, then there is considerable evidence in 

support of 0% being the true value, and it does not move very much with the 

hierarchical "shrinkage estimators". However, if the participant has a relatively 

small sample size, it is a lot more likely that 0 events was simply a chance 

occurrence rather than a reflection of true performance. In such cases, the 

overall mean from all participants is given more weight and the observed 0% 

mortality is "shrunken" toward that mean. 

This approach, although intuitively not satisfying to the participant with 0 events, 

ultimately allows for more accurate risk-adjustment results since it removes some 

of the instability caused by smaller participants with extreme results. It also 

protects participants who might have very high observed mortality based on a 

very small sample size, when in reality that was a reflection of random chance. 

Their results would similarly be shrunk towards the STS mean. 

The following journal article contains more detailed and technical discussion of 

the hierarchical approach to risk-adjustment: Christiansen CL, Morris CN. 

Improving the Statistical Approach to Health Care Provider Profiling. Ann Intern 

Med.1997;127:764-768. 

i. Interpretation manual 

When the risk-adjustment models are applied for the purposes of this report, 

several statistics are computed that allow for performance comparison: OlE 

Ratios, Odds Ratios and Risk-adjusted rates. The following sample page 

illustrates how these risk-adjusted statistics appear in the report for mortality. 

Please note that expected/predicted rates are no longer provided in the 

report. Please see item d. STS Certified Software Package Predicted Risk 

Scores in the Report Overview Risk-adjustment Supplement for information on 

how to calculate expected/predicted rates using results from your STS data 

software vendor. 

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OlE Ratio 

The OlE Ratio is a statistic that allows a participant to gauge whether their 

observed outcomes were beUer, the same, or worse than what would be 

expected given the existing underlying risk factors of the patients. Table 9 below 

contains details for interpreting specific OlE Ratio values. In general, smaller OlE 

Ratios imply beUer performance. See Section IV.c and the Report Overview 

Risk-adjustment Supplement for more details about how the OlE Ratio is 

calculated. 

Starting in 2005, STS risk-adjustment models are re-calibrated each year to 

make them as up-to-date as possible when assessing performance during a 

given year. This re-calibration is needed because overall STS performance 

improves in the interval between development and subsequent updating of the 

STS risk-adjustment models. While updating the STS Risk-adjustment models 

more frequently is the alternative to re-calibration, it is currently not a feasible 

option since vendors currently only update their risk-adjustment models at the 

time of a data specification upgrade. Because the models are re-calibrated for 

each year included in the report, the OlE Ratio reflects performance relative to 

the STS average during that calendar year. This allows participants to 

benchmark their performance relative to a contemporary standard. Model 

recalibration was not performed prior to the Spring 2005 report so participants 

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may have seen a shift in their performance from the last time OlE Ratios were 

provided in the report without recalibration (Spring 2004). 

The following is an example of why the re-calibration is needed and why a 

participant may have seen a shift in their performance. For a hypothetical 

participant 99999 the 2003 CAB operative mortality OlE Ratio was 0.90 in the 

Spring 2004 report. Because the risk-adjustment model was estimated using 

data from 1997-1999, an appropriate interpretation would be that participant 

99999 performed better in 2003 than the average participant performed 

during1997-1999. Under the same methods and for the same time period, the 

overall STS mortality OlE Ratio was 0.80. In this light, participant 99999's OlE of 

0.90 is actually worse than the STS overall OlE of 0.80. Because of the dynamic 

of overall improving participant performance through time, a more appropriate 

comparison group for participants is their current peer groups - the average STS 

participant during a given year. With the new approach to re-calibrate the models 

each year, the overall STS OlE is always 1.0 and for the above example, 

participant 99999's OlE becomes 1.125 (=0.90/0.80). 

Because of this calibration, STS certified software cannot directly produce the 

OlE Ratios in this report. However, we have used a re-calibration method that 

makes it easy for participants to reproduce our results, if desired. See the Report 

Overview - Risk Adjustment Supplement for information about how the recalibrated OlE Ratios can be achieved locally. 

Odds Ratio 

Similar to the OlE Ratio, the Odds Ratio is a statistic that allows a participant to 

gauge its performance relative to other participants after adjusting for patient risk 

factors. More specifically, the Odds Ratio is the ratio of the predicted odds of an 

outcome for a patient relative to what it would be if the surgery were to be 

performed by an "average" STS participant. The "odds" of an outcome is closely 

related to the probability of an outcome and is used in these calculations for 

technical reasons. See Section IV.c for additional details about the Odds Ratio 

and how it differs from the OlE Ratio. The interpretation of the estimated Odds 

Ratio is similar to the interpretation of the OlE Ratio with smaller Odds Ratios 

implying better performance. 

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The following table illustrates the possible interpretations of the OlE Ratio. 

Table 9. OlE Ratio Interpretations' 

Statistic Interpretation 

OlE Ratio> 1 When the OlE Ratio is greater than 1, the participant had an 

observed outcome level that was greater than expected. 

The participant performed worse than expected. 

OlE Ratio < 1 When the OlE Ratio is less than 1 , the participant had an observed 

outcome level that was less than expected. 

The participant performed better than expected 

OlE Ratio = 1 When the OlE Ratio is 1, the participant had an observed outcome 

level equal to expected. 

The participant perfonmed as expected. 

• The interpretations in this table can also be roughly extended to Odds Ratios - values 

less than 1 imply better than average performance, values of 1 imply average 

performance and values over 1 imply worse than average performance. Note that the 

Odds Ratio will generally be closer to 1.0 than the OlE Ratio. It is possible that these two 

measures will be discrepant, but only if they are close to 1.0. 

Risk-adjusted rates 

Risk-adjusted rates are calculated by multiplying the OlE Ratio by the overall 

STS unadjusted event rate for that time period (See the Report Overview Risk 

Adjustment Supplement for more details on calculation of the risk-adjusted rate). 

Because the risk-adjusted rate is so closely related to the OlE Ratio, the 

information provided by these two statistics is similar and the choice of which 

statistic to use is really only a choice of unit of measure. Although one advantage 

of the OlE Ratio is that it is centered around 1.0 regardless of the outcome being 

measured, the risk-adjusted rates have the advantage that they can be easily 

interpreted as a clinically meaningful outcome event percent on a familiar scale. 

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The following table illustrates the possible interpretations of the risk-adjusted 

rate. 

Table 1 D. Risk-adjusted Rate Interpretations 

Statistic Interpretation 

Risk-adjusted rate> When the risk-adjusted rate for a particular adverse outcome 

STS event rate is greater than the STS average rate, then the participant had 

more of those outcomes than expected given their case-mix. 

Risk-adjusted rate < When the risk-adjusted rate for a particular adverse outcome 

STS event rate is less than the STS average rate, then the participant had 

less of those outcomes than expected given their case-mix. 

Risk-adjusted rate = When the risk-adjusted rate for a particular adverse outcome 

STS event rate is equal to the STS average rate, then the participant had the 

same number of those outcomes as expected given their 

case-mix. 

95% Confidence Intervals 

The estimated Odds Ratios and the OlE Ratios provided in the report are 

accompanied by upper and lower 95% Confidence Intervals. The 95% 

Confidence Intervals indicate the range of values within which the analysts are 

95% confident that the true value for the underlying population falls. (The true 

population value is the value that would be observed hypothetically in a very 

large sample of patients.) If the upper and lower bounds of the 95% Confidence 

Intervals for a participant contain the overall STS value, then the value for the 

participant is not statistically different from the STS overall. 

Sample risk-adjustment data and interpretation 

Table 11a below contains hypothetical data on 3 participants and the overall 

STS. This information is provided as a tool to aid in the interpretation of report 

data. The table is followed by text descriptions of how each of the 3 hypothetical 

participants' results would be interpreted. Table 11 b below contains the same 

sample data with a brief interpretation summary next to each value or set of 

values. 

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Table 11a. Sample Data 

Example - CAB Mortality 

Participant A Participant B Participant C STS 

# procedures 495 575 1462 345,674 

# outcome events 5 13 37 6,913 

Observed mortality % 1.0% 2.3% 2.5% 2.0% 

Expected mortality % 3.4% 2.1% 2.5% 2.0% 

Odds Ratio 0.40 1.02 1.00 1.00 

Odds Ratio 95% CI (0.30, 0.82) (0.63,1.64) (0.73, 1.40) -

OlE Ratio 0.29 1.10 1.00 1.00 

OlE Ratio 95% CI (0.00, - 0.75) (0.86 - 1.34) (0.69 - 1.40) -

Risk-adjusted rate 0.58% 2.2% 2.0% -

(0.29 x 2.0%) (1.10x2.0%) (1.00 x 2.0%) 

NOTE. Because the numbers In the table were calculated uSing nonrounded values, you 

may not be able to duplicate identical values. 

Participant A: 

Participant A had a higher than average expected mortality (3.4%) but lower than 

average observed mortality (1.0%) which combined to produce a highly favorable 

OlE Ratio (0.29 1.0/3.4; well below 1.0). The risk-adjusted rate (0.58%) also 

points to lower-than-expected mortality in that it is lower than the overall STS 

mortality rate. The estimated Odds Ratio is 0.40, which is less than 1.0. This 

means that the predicted odds of mortality for a patient undergoing surgery at 

participant A is lower than it would be if the same patient were instead having 

surgery at an "average" STS hospital. The predicted odds of death for any patient 

treated at participant A is lower compared to an average hospital by a factor of 

40% (= 0.40 x 100%). Because the 95% confidence interval on both the Odds 

Ratio and the OlE Ratio do not include the STS value (1.0) the favorable 

mortality results are unlikely to be due to chance variation. In other words, the 

lower-than-expected mortality is statistically significant. 

Participant 8: 

Participant B's observed mortality rate was 2.3% (= 13/575 x 100). The expected 

mortality rate of 2.1 % is obtained from the STS CAB mortality model. It is a 

function of the participant's patient case-mix and cannot be derived from other 

numbers in the table. The OlE Ratio is 1.10 (= 2.3/2.1). The fact that the OlE is 

greater than 1.0 implies that the observed mortality (2.3%) was larger than the 

expected mortality rate (2.1 %). Specifically, the observed mortality exceeded the 

expected rate by 10% (= 100% x [OlE -1]). Finally, the estimated Odds Ratio 

(1.02) is greater than 1.0. This means that the predicted risk of death for a patient 

having surgery at participant B is larger than the predicted risk if the same patient 

was instead having surgery at an "average" STS hospital. The confidence 

interval on the Odds Ratio extends from below 1.0 to above 1.0 (from 0.63 to 

1.64). Because both the Odds Ratio and the OlE Ratio confidence intervals 

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include the STS value (1.0), there is uncertainty about whether the true risk of 

mortality for a future hypothetical patient is lower or higher than average. The 

excess mortality observed at participant B may be attributable to chance 

variation; it is not statistically significant. 

Participant C: 

Participant C's observed mortality rate (2.5%) is higher than the overall STS 

average mortality rate (2.0%). However, its expected mortality rate (2.5%) is also 

higher than average (2.0%), reflecting a riskier than average patient population. 

By coincidence, the observed mortality rate matches the expected mortality rate 

exactly. As a result, the OlE is exactly equal to 1.0 and the participant's riskadjusted mortality rate is equal to the overall STS average (2.0% = 1.0 x 2.0%). 

This is uncommon. Because the expected number of deaths is usually a fraction, 

whereas the observed number is a whole number, the observed mortality rate is 

rarely equal to the expected rate. 

Table 11 b. Sample Data and Interpretation 

. ,; 

Participant A . Participant 6 Participant C STS 

# procedures 495 575 1462 345,674 

# outcome events 5 13 37 6,913 

O~served mortality % 1.0% 2.3% 2,5% 2.0% 

j Expected 2.0% 1 Expected 2.0% 1 Expected 2.0% 

Expected mortality % 3.4% 2.1% 2.5% 2,0% 

1 Expected 2.0% 1 Expected 2.0% ) Expected 2.0% 

Odds Ratio 0.40 1.02 1,00 1,00 

<1.0; Odds of death >1,0; Odds of =1.0; Odds of death 

are better than at death are worse are same as at 

average STS site than at average average STS site 

STS site 

Odds Ratio 95% CI (0,30.0,82) (0,63, 1,64) (0,73, 1.40) - Does not include STS Does include STS Does include STS 

1.0=Statistically 1.0=Not 1.0=Not Statistically 

Significantly different Statistically Significantly 

Significantly different 

different 

OlE Ratio 0.29 1.10 1.00 1.00 

<1,0=Better than >1.0=Worse than =1.0=As Expected 

Expected Expected 

OlE Ratio 95% CI (0,00-0.75) (0,86 -1.34) (0,69 - 1.40) - Does not include STS Does include STS Does include STS 

1.0=Statistically 1.0=Not 1.0=Not Statistically 

Significantly different Statistically Significantly 

Significantly different 

different 

Risk-adjusted rate 0.58% 2.2% 2.0% - (0.29 x 2,0%) (1,10x2.0%) (1.00 x 2,0%) 

O/E*STS National O/E'STS National O/E'STS National 

j STS ISTS =STS 

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A note on interpretation 

Participants that have results that are statistically different from the STS (the 

range between participant Confidence Intervals does not contain the STS value) 

should approach the use of that information with caution. Despite the utility of 

risk-adjustment to allow for fair comparisons, certain limitations should be kept in 

mind: 

Extreme values are possible due to chance. If a surgeon only operated one time, 

the surgeon's observed mortality rate would either be 0% (= 0/1 x 100%) or 

100% (= 1/1 x 100%). A mortality rate of 0% would be extremely low; 100% 

would be extremely high. Neither outcome would accurately reflect the surgeon's 

true ability, which probably lies somewhere between 0% and 100%. Because 

surgical outcomes have a random component, a large sample of patient 

operations is required in order to accurately measure a surgeon's performance. 

Even with one hundred patients, the death of a single patient can cause the 

mortality rate to jump by 1 %. (The risk-adjusted mortality will also be substantially 

changed by a single patient outcome.) The exact value of a statistic such as the 

observed mortality rate or the observed to expected ratio must always be 

considered in conjunction with its confidence Interval, which shows the range of 

plausible values based on the sample size. 

Variations in coding of risk factors could explain extreme values. The validity of 

the risk-adjusted results relies on consistent and accurate coding of risk factors 

and surgical outcomes. In reality, there may be some variation in the way risk 

factors and outcomes are coded by two different participants. If one hospital 

tends to over-state the risk profiles of its patients while another hospital understates the risk profiles of its patients, the hospital that over-states the risk profiles 

will have an unfair advantage. To minimize bias, it is essential to pay close 

attention to STS data definitions when coding events and risk factors. 

Not all risk factors are captured in the model. Risk-adjustment attempts to level 

the playing field by adjusting for the risk profiles of the participant's patient 

population. However, there are potentially difficult to measure factors that are not 

included in the risk adjustment model and which may increase or decrease a 

patient's risk of an adverse outcome. For this reason, two patients having exactly 

the same measured risk factors prior to surgery might actually have substantially 

different real risks. If a participant tends to treat patients that are at greater or 

lower risk than they might appear based on the measured risk factors, this may 

bias their risk-adjusted results upward or downward. 

v. Participant-Specific Data Quality Summary 

Information about your participant organization's data quality is provided in the 

Participant-Specific Data Quality Summary (Harvest 1 and 3 only) to help you 

interpret and weight your reported results. We encourage you to review this 

information to help you assess the accuracy and reliability of your report. 

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Table 12. Procedure Identification Table 

Variable CAB Only AV Replace AV Replace + MV Replace MV Replace-+ AV Replace + MV Repair MV Repair + 

Short Name CAB CAB MV Replace CAB 

OpCAS Ye, No/Missing Ye, No/Missing Yes No/Missing No/Mlssmg Ye, 

OpValve NofMisslng Yes Ye, Yes Yes Ye, Yes Ye, 

VAD NolMlssing No/Mlssmg No/Missmg No/Missing No/Miasmg No/Missing i No/Missing NofMissing 

OpAortic No/Missing Replacement Replacement No/Missing No/Missing Replacement No/Missing No/Missing 

OpMltral No/Missing No/Missing No/Missing Replacement Replacement Replacement 

OpTri<:us No/Missing No/Missing No/Missing NofMissing No/Missing No/Missing NoIMissing No/Missing 

OpPulm No/Missing No/Mlssmg No/Missing No/Missing No/Missing NorMissing No/Missing No/Missing 

OpONCard No/Missing NolMissing No/Missing No/Missing No/Missing No/Missing i No/Missing No/Missing 

OpOCard Do no! use OpOCard for exclusions. Use specific variables below. 

OCarLVA No/Missing No/Missing No/MiSSing No/Missing No/Missing No/Missing I No/Missing No/Missing 

OCarVSD No/Missing No/Missing No/Missing No/Missing No/Missing NolMissing No/Missing 

OCarASD NolMlssing No/Missing NolMissing No/Missing No/Missing No/MIssing No/MIssing ~:~::::~: --

OCarBati NolMissing No/Missing No/Missing No/Missing No/Missing No/Missing No/Missing No/MISSing 

OCarSVR NofMissing NofMissing No/Missing No/Missing No/Missing No/Missing No/Missing No/Missing 

OCarCong NolMisslng No/Missing NoIMissmg No/Missing No/MIssing No/Mlsslng No/Missing No/Missing 

OCarLasr No/Missing NO/Mlssmg No/Missing No/Missing No/MIssing NolMlSSlng No/Missing No/MIssing 

OCarTrma No/MisSing No/Mlssmg NO/Missmg No/Missing No/Missing No/Missing No/Missing NoIMiSSlng 

OCarCrTx No/Missing No/Missing No/MISSing No/MIssing No/Missing No/Missing No/MISSing No/Mlsslng 

OCarACD Do nol use OCarACD for exclUsions. 

OCarAFib None/Missing None/Missing None/MIssing None/MIssing None/Missing None/MIssing None/MIssing None/MIssing 

ONCAoAn No/Missing No/Missing No/Missmg No/Missing No/Missing No/Missing NoIMissing NolMlssing 

OCarOthr No/Missing No/Missing No/MIssing No/MiSSing NO/Mlssmg No/Missing NolMlssing No/Missing 

** Annuloplasty Only Q[ Reconstruction wI Annuloplasty QL Reconstruction w/out Annuloplasty. 

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Table 13. Calculated Variables 

Demographics Body Mass Index fBMIl 8M! = (WeightKg)/ (HeightCm 110oi'. 

Multiple Races 

Note: BMI categories (underweight, normal, etc.) are those accepted by the National 

Institutes of Health and represent a departure from previous STS reports. 

When more than one race is indicated: RaceCaucasian, RaceBlack, RaceAsian, 

RaceNativeAm, RacNativePacific, RaceOther. Multlple Races is only calculated for 

data version 2.61 records. 

Hospitalization T ota! Length of Stay Tota! length of stay is the number of days from the date of admission (AdmitDt) to the 

date of discharge (DischDT). 

Previous 

Interventions 

Post-procedure Length of Stay Post-procedure length of stay is the number of days from the date of surgery (SurgDT) 

to the date of discharge (DischDT) 

Short Post~procedure Length of Stay For the time period through 1213112007, a "short stay" was when the post~procedure 

length of stay was less than 6 days, Beginning 1/1/2008 this definition was changed to 

take into account inhospltal mortallty ~ a "short stay" is when the patient was discharged 

alive and the post~procedure length of stay is less than six days, 

Long Post¥procedure Length of Stay A "long stay" is when the post-procedure length of stay is greater than fourteen days. 

Previous Cardiac Surgery When the patient has undergone any previous CAB operations, valve operations, or 

other cardiac operations (with OT without cardio"pulmonary bypass). For versions 2,35 

and 2.41, the database variables involved in this determination are: PrCBNum. 

PrCNNum, PreAS, PrValve, PrOthCar, Beginning with data version 2.52,1, the 

variables involved in this determination are Incidenc, PrCAB, PrValve, PrOthCar. 

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Information 

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~ 

First ReoperationfSecond+ 

Timing of Previous PCI 

Distal Anastomoses - Toti31 

Internal Mammary Artery Used 

Radial Artery Used 

Off-Pump Procedure 

Skin Incision Duration 

Clotting Agents 

For those patients with a previous cardiac surgery, indication of the numbar of prevIous 

surgeries. For versions 2.35 and 2.41, the database variables involved in this 

determination are: PrCBNum, PrCNNum, preAS, PrValve, PrOthCar. Beginning with 

data version 2,52.1, the variables involved in this determination are Incidenc, PreAB, 

PrValve. PrOthCar. 

Whether the patient has undergone any previous PCI. For versions 2.35 and 2.41, the 

database variables involved in this detennination are: PrNSStnt and PrPTCA. Beginning 

with data version 2.52.1, the vanable involved in this determination is POCPCI 

For versions 2.35 and 2.41 if patient had both a PrNSStnt and a PrPTCA, timing was 

determined by the first to occur. Beginning with data version 2.52.1, timing is determined 

with the variable POCPClln. 

Total number of distal anastomoses is the number with arterial conduits plus the number 

with vem grafts 

Any of the following internal mammary arteries: left, right. both 

Any of the following radial arteries used: left, right, both 

For version 2.35 data, a procedure is assumed to be off-pump if cardioplegia is not 

indicated as used and perfusion time equals zero minutes. For version 2.41 data, the 

variable CPBUsed reflected the pump status of a procedure. For data versions 2,52.1 

and 2.61, CPBUtii is used. 

Time interval between incision start date/time {SIStartn and incision stop date/time 

(SIStopT). 

Time interval between OR entry dateltime (OREntryDT) and OR exit date/time 

(ORExltDT) 

Anyone of the following intraop medications were indicated: IMedAprot, IMedEACA, 

IMedDesmo, IMedTran. Clotting Agents is only calculated for data version 2.61 records. 

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Postoperative 

Information 

Initial Ventllation Hours 

Total Ventilation Hours 

Total Blood Products 

Pdor to data version 2.61 initial ventilation hours were captured in a single variable, 

VentHrsl. Beginning with data version 2.61 initial ventilation hours is a variable 

calculated as the number of hours between ORExitDT and ExtubateOT 

Prior to data version 2.61 total postoperative ventilation hours were captured in a single 

vanable, VentHrs. Begmning with data version 2.61 total postoperative ventilation hours 

is a variable calculated as the sum of the calculated initial ventilations hours and the 

variable additional ... entHatian hours (VentHrsA) 

The sums of the individual intraoperative and postoperative blood product units, 

Complications Any Maior Complications or Mortality This is a measure of combined outcomes. It is true if any of the following are indicated: 

Any Neurological Complications 

Any Reoperation Complications 

Any Vascular Compiications 

Any infection Complications 

Any Pulmonary Complications 

Any Other Complications 

Mortality Observed Operative Mortality 

NOTE: Variable short names are bolded 

Operative mortality. reoperation for any cause, permanent stroke. prolonged ventilation, 

deep sterna! wound infection. or renal failure. 

Any of the neurological complications found on the STS data collection form.: 

Reoperation for any of the reasons found on the STS data collection form. 

Any of the vascular complications found on the STS data coHection form. 

Any of the infection complications found on the STS data collection form, 

Any of the pulmonary complications found on the STS data collection form. 

Any of the other complications found on the STS data collection form. 

Operative Mortality (MtOpO) adjusted for between-variable inconsistencies. 

29 - OV General 
213 


85440.164

30 - OV General 
214 


85440.165

31 - OV General 
215 


85440.166

32 - OV General 
216 


85440.167

A. 

The Society of Thoracic Surgeons 

Adult Cardiac Surgery Database 

Data Collection Form Version 2.73 

January 14, 2011 

~raPhi~ I Patient F_j~t Name: I Patient M_i~?!~,Name: 

PatLName 90 PalFName \1001 PatMName \ 120} 

~~Zi~~~ecurityNumber: ____ - ---- -~.-- I ~:~~~~INR~~~Number: 

Patient's Address: 

Street Address: 

PatAddr 180 

Region: 

PatRe ion 200 

Is This Patient's Permanent Address:: Yes' No 

PermAddr 230) 

1'1;:, Patient's Permanent Address: 

I ZIP Code: PatZIP(210) 

:. Female 

I Country: 

PstCountry (220) 

~;~~:t~J~~~O) I City: 

PatPermCily (250) 

Region: 

PatPcrmRe Ion (260) 

Race,Sdp' a: t',;)t arp1 ' White: BlackJAfrican American: 

RaceCaucaslan (290) L~ Yes No RaceBlack (300) L Yes No 

L Yes :-0 No 

,_ Yes =.i No 

Asian: RaceAslan (310) Yes No Am Indian/Alaskan Nat: 

Native Hawaiian/Pacific Islander; Yes _ No RaceNativeAm (320) 

rH"'iC::spa=ni::ic', L-::a"tin::oC:o:::'''s:Cpa::nC:is:;:'hR'''~:i~~:''~''i~v=it~,:-~a",C'''ff~"C ~'73~",~"-) -:-c""'N:cO----------O"'t"'h"'e'''-': RaceOther (340) 

Ethnicltv 1350 

Referring Cardiologist: 

Ref Card 360 

C. Hospitalization 

Hospita! Name: 

HospName (3aO) 

I Referring Physician; 

Ref Ph s (370} 

Hospita! ZIP Code: 

HospZIP (390) 

~Z:~~~IJ ~~~\Onal Provider Identifier: ____ • _________ _ 

Payor - ,SC·t:'2! 011 thai ap:' .. 

Government Health Insurance: PayorGov (420) 0 Yes 0 No 

Commercial Health Insurance: 0 Yes 0 No PayorCom (510) 

Health Maintenance Organization: 0 Yes 0 No PayorHMO {520} 

Non~U.S. Insurance; PayorNonUS 0 Yes 0 No (530) 

None I Self: PavorNS (540 0 Yes 0 No 

© The Society of Thoracic Surgeons 2011 

Medicare: 0 Yes 

PayorGovMcare (430) 

Medicaid: 0 Yes 0 No PayorGovMcaid (460) 

State~Specific Plan: 0 Yes 0 No PayorGovState (480) 

Correctional Facility: 0 Yes 0 No 

PayorGovCor (500) 

Paga1 of 16 

Hospital State: 

HospStat (400) 

Health Insurance Claim Number: 

"'Mcced"'i=ca:::re'"""F"'e=-=e'"F"'oC:-, s""e=rv7~;:N~~~~ ~4~~ PayorGovMcareFFS (450) 

Military Hea!th Care: 0 Yes 0 No PayorGovMI!(470) 

Indian Health Service: 0 Yes 0 No 

PayorGovlHS (490} 
217 


85440.168

ArnvalDt (550) 

Admit Source: 

AdmitSrc (580) 

Elective Admission 

Emergency Department 

IArnvaffm (560) !AdmitOI (570) 

Transfer in from another acute care facility Other Hospital Performs Cardiac Surgery 0 Yes 0 No 

OthHosCS (590) 

[ Other 

D. Risk Factors---

Weight (kg): W81ghtKg (630) Heioht em: HelghtCm (640) 

Cigarette Smoker: DYes 0 No 1'\" Current Cigarette Smoker: DYes D No 

CigSmoker (650) ClgSmokerCurr (660) 

Other Tobacco Use: DYes 0 No OthTobUse (661) 

Family History of Premature Coronary Artery Disease: 0 Yes 0 No .1 Last Hematocrit __ 

FHCAO (670) He! (680) I Last WBC Count: WBe (690) -_--

:l!:t~~~~! ~~~nt Prior to Surgery: __ I :~~n;~~onal Normalized Ratio prior to Surgery: ___ 

HIT Antibodies o Ves 0 No 0 Not Applicable I Total Bilirubin Prior to Surgery; ___ 

HITAnh 711 TotBlrbn 720) 

+ ~;:I~~~~m;~trior to Surgery:__ I ~ {~L ~Je~~6Prior to surgery: -- 1 Last Creatinine Level Prior to Surgery: ___ 

CreatLst 750 

g;i:~~:~~78~)Yes 0 No',,: D~fa~~~~(~~~trol: 0 None o Diet o Oral o Insulin o Other 

Dyslipidemia: 0 Yes 0 No ! Dialysis: 0 Ves 0 No I MELD Score: --(System Calculation) I Hypertension: DYes ONo Dys" (800) DialysIs (8~Ol MELDS" (8"5)- Hypertn (8201 

Infectious Endocarditis: 0 Yes 0 No 

, Infectious Endocarditis Type: 0 Treated D Active InfEndTy (840) 

Infectious Endocarditis Culture: !nfEndCult (850) 

D Culture negative 0 Staphylococcus aureus 0 Streptococcus species 

, e staDhviococcus D Enterococcus species 0 Funeal o Other 

Chronic Lun Moderate o Severe ChrLungD (860 

Pulmonary Fu n es one: U es uNo PFT 

(880) 

FEV1 % Predicted: ___ 

FEV1 (890) 

DLCO Test Perlormed: DYes o No i DLCO % Predicted: -- DLCO 892) DlCQPred 893 

Arterial Blood Gas Periormed: 0 Yes 0 No rre~ Oxygen Level; ___ Carbon Dioxide Level: 

ABG 900 P02 910) PC02 920 

~~~~(~~)gen: 0 Ves 0 No ~~:;~~4~tdication or Ora! Bronchodilator Therapy: DVes D No 

Sleep Apnea: 0 Yes 0 No Liver Disease: DYes 0 No 

Sf Aon 950 UverO!s 960) 

Immunocompromise Present: DYes 0 No Peripheral Artery Disease: DVes 0 No 

~~L- PVD 980 

Unresponsive ~)eurOIOgic State: 0 Yes 0 No Unres ~~!~~:~:10~1~es 0 No JStat 1000 

Cerebrovascular Disease: DYes 0 No evo (1010) 

!;Yes , PriorCVA: DYes ONo Prior CVA-When: o Recent «=2 Wk.) 0 Remote (>2 wk.) 

CVA(1020) CVAWhen (1030) 

CVDTIA: DYes D No CVOTIA (1050) 

CVD Carotid stenosis: D None o Right o Left o Both CVDCarSten (1070) 

I' Severity of stenosis on the right carotid artery: 080-99% o 100% CVDStenRt (1071) 

Severity of stenosis on the left carotid artery: 080- 99% 0 100% eVOStenLft (1072) 

Historv of prevIous carotid art!:!!)' sumerv and/or stenting: 0 Yes 0 No CVDPCarSurg (1080) 

Illicit Drug Use: 0 Yes 0 No J Alcohol Use: 0 <;; 1 drink/week o 2~7 drinks/week o >=8 drinks/week 

IVDruoAb 1130 A!eoho!(1131) 

Pneumonia: 0 No o Recent o Remote I ~:~~~;~~~I ~~~iation: 0 Yes 0 No I Cancer Within 5 Years ; Pneumonia \1140 Cancer (1160) 

Five Meter Walk Test Done: DYes ONo FiveMWa!kT est (1161) 

I' Time 1: (sees) 

FlveMWalk1(1170) 

E. Previous Cardiac Interventions 

Previous Cardiac Interventions: 0 Yes D No 

PrCV!nt (1200) 

© The Society of Thoracic Surgeons 2011 

Time 2: ___ (secs) 

FiveMWalk2 1180">, 

Page 2 of 16 

Time3: ___ (sees) 

FiveMWalk3 1190 

DYes 0 No 

I 
218 


85440.169

Previous CAB prior to current admission: 0 Yes 0 No PrCAB (1215) 

Previous Valve: DYes 0 No <' PrValve (1216) 

Previous Aortic Valve Replacement - Surgical: 0 Yes 0 No PrevProcAVReplace (1220) 

Previous Aortic Valve Repair - Surgical: 0 Yes 0 No PrevProcAVRepair (1230) 

Previous Mitral Valve Replacement - Surgical: 0 Yes 0 No PrevProcMVRep!ace (1240) 

Previous Mitral Valve Repair - Surgical: 0 Yes 0 No PrevProcMVRepatf (1250) 

Previous Tricuspid Valve Replacement - Surgical: 0 Yes D No PrevProcTVReplace (1260) 

Previous Tricuspid Valve Repair - Surgical: 0 Yes 0 No PrevProcTVRepalf (1270) 

Previous Pulmonic Valve Repair' Replacement - Surgical: 0 Yes 0 No PrevProcPV (1280) 

Previous Aortic Valve Balloon Valvuloplasty: DYes 0 No PrevPracAV8al! (1285) 

Previous Mitra! Valve Balloon Valvuloplasty: 0 Yes 0 No PrevProcMVBall (1290) 

Previous Transcatheter Valve Replacement 0 Yes 0 No PrevProcTCVRep (1300) 

Previous Percutaneous Valve Repair: 0 Yes 0 No PrevProcPercVRepmf (1310) 

Indication for Reoperation: 0 Structural Prosthetic Valve Deterioration 

indReop (1340) 0 Non-structural prosthetic valve dysfunction 

,Primary type: 0 Paravalvular Leak D Hemolysis 

NonSIVDys (1350) 0 Entrapment by pannus, tissue, or suture 

o Sizing or positioning issue 

o Prosthetic Valve Endocarditis 

o Valve Thrombosis 

o Failed Repair 

D Repeat valve procedure on a different valve 

o Other 

o Other 

Exact Date of PrevIous Valve Procedure Known: 0 Yes 0 No PrVa!DtKnown (1410) 

Date of Previous Valve Procedure: _ ~ 1 _ _ J ____ PrValveDate (1420) 

Estimate Number of Months Since Previous Valve Procedure: ___ PrValveMonths (1430) 

PrevIous Other Cardiac: 0 Yes 0 No PrOthCar (1440) Previous Arrhythmia Surgery: DYes 0 No POArr (1445) 

Previous Congenital: 0 Yes D No PrOthCongen (1450) 

Previous ICD (Implantable Cadioverter/Defibrillator): 0 Yes 0 No PrOCAICD (1460) 

Previous Pacemaker: DYes 0 No PrOCPace (1470) 

Previous PCI (Percutaneous Cardiac Intervention): 0 Yes 0 No POCPCI (1480) 

PCI Performed Within This Episode Of Care: 0 Yes, at this facility D Yes, at some other acute care facility D No 

POCPCIWhen (1481) 

Indication for Surgery: 0 PCI Complication 

POCPClndSurg (1490) 0 PCI FailUre without Clinical Deterioration 

o PCI/CABG Hybrid Procedure 

PCI Stent : 0 Yes 0 No 1 Stent Type: 0 Bare metal 0 Drug-eluting 0 Unknown 

POCPCISt (1500) POCPC!StTy (1510) 

PCI Interval: 0 <= 6 Hours 0> 6 Hours POCPClln (1520) 

Other Previous Cardiovascular Intervention: 0 Yes 0 No POCO (1530) 

F. Preoperative Cardiac Status 

Prior Myocardial Infarction: DYes 0 No '" PrevMI (1540) 

MI When: 0 <=6 Hrs o >6 Hrs but <24 Hrs Dlto7Days 0 Days 0>21 Davs MIWhen 1550) 

Anaina! Classification Within 2 weeks: 0 No Svmotoms, No An ina DCCAI I o CCA III o CCA IV A,oi"IClasSl1570\ 

Heart Failure Within 2 weeks: 0 Yes DNo n •• g!!::ss~~~~~if5~~YHA: I o Class!! o Class HI o Class IV 

CHF 1580 

Prior Heart failure: 0 Yes o No PnorHF (1590) 

Cardiac Presentation on Admission: o No Symptoms,No Angina 

CardPres (1610) o Unstable Anaina g ~~~~~~~e~~!:~~!~t~(~~~~~~~~f) g ~~~I::a~~~~1 (STEMJ) 

Cardi enic Shock: 0 Yes 0 No CarShock (1620) 

DYes D No Resu$c (1630) 

Arrh~:~ah~i~e;:pe~ NO~~c~N~~~g~e~ ~~~nt, ~e;~2nl . ArrhythWhen (1650) 

Second Degree Heart Block: DYes 0 No 

ArrhyVtach (1660) ArrhyVtachHrtB!k (1670) 

Sick Sinus Syndrome: 0 Yes 0 No Third Degree Heart Block: 0 Yes 0 No 

ArrhyVtachSlcSinSyn (16BO) ArrhyTHB (1690) 

Afib/Aflutter: DYes 0 No AnhyAflb (1700) 

'''s:; Type: 0 Paroxysmal 0 Continuous/Persistent ArrhyAfibTy (1701) 

G. Preooerative Medications 

Beta Blockers: 0 Yes 0 No 0 Contraindicated MedBeta 1710 

ACE or ARB Inhibitors WithIn 48 Hours: 0 Yes 0 No MedACEJ48 (1730 

Nitrates-LV.: 0 Yes 0 No MedNitlV (1740 

Anticoagulants: 0 Yes 0 No d \ ,;~ Medication Name: 0 Heparin (Unfractionated) o Heparin (Low Molecular) 

MedACoag (1750) MedACMN (1760) 0 ThrombIn Inhibitors o Other 

Preooerative Antiarrhvthmics: 0 Yes 0 No MedAArrhv (1770) 

© The SOCiety of ThoracIc Surgeons 2011 Page 3 of 16 
219 


85440.170

-------------------------------1 

'-,s ADP Inhibitors Discontinuation; ~_ (# days prior to surgery) 

MedADPIDI$ (1860\ 

Da s: 0 Yes 0 No MedA It5Da s (1870 

hibitor: 0 Yes 0 No Medication Name: 0 Abciximab (ReoPro) 0 Eptifibatlde (Integrilin) 

MedGP (1880) MedGPMN (1890) 0 Tirofiban A rastat 

Thrombol ics within 48 hours: 0 Yes 0 No MedThrom (1900) 

"H', "He=mod=n=a=<mj=csI""C""athlE=ch:::co-----------------------------, 

Cardiac Catheterization Performed: 0 Yes 0 No I Cardiac Catheterization Date: __ , __ "" _, __ _ 

Car er 1910 CarCathDt {1920 

Diseased Vessels: 0 None 0 One 0 Two 0 Three NumOisV (1930) 

Left Main Disease:>::::: 50%: 0 Yes 0 No lMamDls (1940) 

Proximal LAD >= 70%: 0 Yes 0 No ProxlAD (1941 

Ejection Fraction Done: 0 Yes 0 No HDEFD (1950) 

HDEF (1960) Ejection Fraction: ___ (%) 

HDEFMeth Ejection Fraction Method: 0 LV Gram 0 Radionudeotide 0 Estimate 0 ECHO 0 MRI/CT 0 Other 1970 

LV S stolic Dimension: mm LVSD (1980) LV End~Diastoljc Dimension: mm LVEDD (1990) 

PA Systolic Pressure Measured: 0 Yes 0 No PA Systolic Pressure: ___ mmHg(highest prior to surgery) 

PASYSMeas 12020 PASYS 2030 

Aortic Valve Disease; 0 Yes 0 No ':' 

Aortic Etiology: 

VDAoEt (2090) I Root Abscess: 0 Yes 0 No VOEndAB (2110) 

Type: 0 Bicuspid 0 Other VDCongenT (2120) 

Type 0 Martans 0 Other Connective tissue disorder 

VDPrimAo (2130) 0 Atherosclerotic Aneurysm 0 Inflammatory 

o Aortic Dissection 0 Idiopathic Root Dilation 

o LV Outflow Tract Obstruction: 

Type: 0 HoeM VDLVOutOb (2140) 0 Sub~aortjc membrane 

o Sub-aortic Tunnel 

o Supravalvular Aortic Stenosis 

o Tumor: ,Type: 0 Myxoma 0 Papillary fibroelastoma 0 Carcinoid 0 Other 

VOAortTumor (2150) 

o Trauma 

o Other 

Aortic Stenosis: 0 Yes 0 No ,VDStenA (2152) 

Smallest Aortic Valve Area: ___ em:.! VDAoVA (2153) 

Highest Mean Gradient: ___ mmHg VDGradA (2154) 

Aortic Insufficiency: 0 None 0 TracefTrivial 0 Mild 0 Moderate 0 Severe VDlnsufA (2155) 

Mitra! Valve Disease: 0 Yes 0 No,ji Ye-:, VOMit (2160) 

Mitral Etiology: 0 Annular or Degenerative Disease 

VDMitET (2170) 

o Endocarditis 

o Rheumatic 

o ischemic 

o Congenital 

Location: 0 Posterior Leaflet 0 Anterior Leaflet 0 Bileaflet 

VDMitDegLoc (2180) 

Type: 0 Pure Annu!ar Dilation 0 Mitral Annular Calcification 

VDMitAnOegDis (2190) 

Type: 0 Acute i Papillary Muscle Rupture: 0 Yes 0 No 

o Chronic VDMitlsTy (2210) VDMitPMR (2220) 

o Hypertrophic Obstructive Cardiomyopathy (HOCM) 

o Tumor: I' -1A~C:' ',Type: 0 Myxoma 0 Papillary fibroelastoma 0 Carcinoid 0 Other 

VDMitTumor (2221) 

o Trauma 

o Non~ischemic cardiomyopathy 

o Other 

Mitra! Valve Disease Functiona! Class: 0 Type! 0 Type II 0 Type!!la 0 Type !lIb VDMitFC (2230) 

Mitral Stenosis: 0 Yes 0 No VDStenM (2240) 

Smallest Mitral Valve Area : __ ~ cmLVDMVA (2250) 

© The Society of Thoradc Surgeoos 2011 Page 4 of 16 
220 


85440.171

Highest Mean Gradient: ~~_ mm Hg VDGradM (2260) 

Mitral Insufficiency: 0 None 0 Trace/trivia! 0 Mild 0 Moderate 0 Severe VOlnsufM (2270) 

Tricuspid Valve Disease: 0 Yes 0 No _1'-.:: lOS ,VOTr (2280) 

Tricuspid Etiology: D Functiona! 

VDTrEt (2290) D Endocarditis 

D Congenital 

DTumor 

o Trauma 

DOther 

Tricuspid Stenosis: DYes D No VOStenT (2300) 

Tricusoid Insufficiencv: 0 None 0 Trace/trivia! 0 Mild 0 Moderate 0 Severe VDlnsulT (2320) 

Pulmonic Valve Disease: 0 Yes 0 No :'1"', VOPulm (2321) 

Pulmonic Stenosis: DYes D No VDStenP (2330) 

Pulmonic Insufficiency: 0 None 0 Trace/trival 0 Mild 0 Moderate 0 Severe VDlnsufP (2340) 

r.1'.~O~D,e=m~tzWe=-~----------------------------------------------~--------·-·----

;\~;gge~~n/23"'5"O):----------------­

Taxpayer Identification Number: 

~~ri~~~2~~5) ------..... -------....... - TIN (2370) 

Incidence: 0 First cardiovascular surgery o Third re~op cardiovascular surgery 

tncidenc(2380 D First re-op cardiovascular surgery o Fourth or more re~op cardiovascular surgery 

) 

o Second re-op cardiovascular surgery 

Status: 0 Elective 

Status (2390) D Urgent UrgntRsn (2400) 

Reason: 0 AMI 0 !ABP D Worsening CP D CHF 0 Anatomy DUSA D Rest Angina 

o Valve Dysfunction DAortic Dissection DAngiographic Accident DCardiac Trauma 

o Infected Device 0 Syncope 0 PCI/CABG Hybrid 0 PCI Failure w/out clinical deterioration 

D Emergent EmergRsn (2410) 

Reason: 0 Shock Cire Support 0 Shock No Cire Support D Pulmonary Edema 0 AEMI 

D Ongoing Ischemia 0 Valve Dysfunction 0 Aortic Dissection 

o Angiographic Accident 0 Cardiac Trauma D Infected Device D Syncope 

o PCIICABG Hybrid 0 Anatomy 

o Emergent Salvage 

Was case previously attempted during this admission, but-canceled: 0 Yes 0 No PCancCase (2415) 

Date of previous case: ~_I __ 1____ PCancCaseDt (2416) 

Timing of previous case: D Prior to induction of anesthesia 0 After induction, prior to incision 

PCancCaseTmg (2417) 0 After incision made 

Reason previous case was D Anesthesiology event 0 Cardiac arrest 

canceled: PCancCaseRsn D Unanticipated tumor 0 Other 

(2418) 

Planned previous procedure: CABG 0 Yes 0 No 

PCancCaseCAB (2419) 

Mechanical Assist Device 0 Yes D No 

PCancCaseMech (2421) 

Other Non~cardjac 0 Yes 0 No 

PCancCaseONC (2423) 

Was the current procedure canceled: 0 Yes 0 No CCancCase (2424) 

o Equipment/supply issue 

Valve 0 Yes 0 No 

PCancCaseVal (2420) 

Other Cardiac 0 Yes 0 No 

PCancCllseOC (2422) 

j' 'yes Canceled Timing: 0 Prior to induction of anesthesia 0 After induction, prior to incision 

CCancCaseTmg (2425) 0 After incision made 

Canceled Reason: o Anesthesiology event 0 Cardiac arrest D Equipmentfsupply issue 

CCancCaseRsn (2426) 

Planned procedure: 

o Unanticipated tumor 0 Other 

CABG DYes 0 No 

CCancCaseCAB (2427) 

Mechanical Assist Device 0 Yes 0 No 

CCancCaseMech (2429) 

g~~~~~~sr:;~~i(~~31) 0 Yes 0 No 

Valve 

CCancCaseVal (2428) 

Other Cardiac 

CCancCaseOC (2430) 

DYes 0 No 

DYes 0 No 

Operative Approach: o Full conventional sternotomy 0 Partial sternotomy 0 Right or left parasternal incision 

o Left Thoracotomv 0 Riaht Thoracotol1"lY 0 Transverse stemotol11Y (includes clamshell) 

© The Society of ThoraCIC Surgeons 2011 Page 5 of 16 
221 


85440.172

o Minimally invasive OPApp (2435) 

Robotic Technoloav Assisted: 0 Yes 0 No Robotic (2436) 

Coronary Artery Bypass: 0 Yes 0 No OpCAB (2437) 

(If "Yes" complete Section J) 

vaIV~a~~~g;Z~t~~:~X~I~n~: i~ ~es{!f~Y~~ ~>O!1)Plete Sectlo~ .~)_?pValve (2440) 

e:I~:;~~~~~~~~: 0 Aortic 0 Mitral 0 Tricuspid 0 Pulmonic 

Explant Type: 0 Unknown 0 Mechanical Valve 0 Bioprosthetic Valve 

ValExpTyp (2460) 

Device 

Manufacturer: 

VaIExpMan(2461} 

Explant Device: 

o Annuloplasty Device 0 Mitral cnp 

o None (Homograft or 

Pulmonary Autograft) 

OATS 

o Baxter 

o Biocore 

o Bjork-Shiley 

o CarboMedics 

o Carpentier-Edwards 

o Cosgrove~Edwards 

DCryolffe 

o Cryolife O'Brien 

o Edwards 

o Genesee 

o Hancock 

o lonescu~Shiley 

o Labcor 

o UfeNet 

!', ;:.';':~ :.~ ,'I~S !\o?y ~,()L:l\\.va!ExpDev (2462) 

o Transcatheter Device 

o UUehei-Kaster o OmniScience 

o MCRI o Sarin 

o Medtronic o Sorin-Puig 

o Medtronic Colvin Galloway o St. Jude Medical 

o Medtronic-Duran o S1. Jude Tailor 

o Medtronic-Hall o Starr-Edwards 

o Mitroflow o Ultracor 

o OmniCarbon o Unknown 

o Other 

Second Valve Prosthesis Explant; 0 Yes 0 No Va!Exp2 (2463) 

e:I~:;;~~~~06~\ 0 Aortic 0 Mitral 0 Tricuspid 0 Pulmonic 

Explant Type: 0 Unknown 0 Mechanical Valve 0 Bioprosthetic Valve 

ValExpTyp2 (2465) 

o Annuloplasty Device o Mitral CHp o T ranscatheter Device 

Device DCryolife o LHiehel~Kaster o OmniScience 

Manufacturer: 

o None (Homograft or 

Pulmonary Autograft) 

OATS 

o Cryolite O'Brien o MCRI o Sorin 

VaIExpMan2(2466) o Edwards 

o Baxter o Genesee 

o Biocore o Hancock 

o Medtronic 

o Medtronic Colvln 

Galloway 

o Sorin-Puig 

o St. Jude Medical 

o S1. Jude Tailor 

o Bj{jrk~ShHey o !onescu~Shiley o Medtronic-Duran o Starr-Edwards 

o CarboMedics 

o Carpentjer~Edwards 

o Cosgrove-Edwards 

2'" ATS Mecl1anlcal ProsthesIs 

3 '" 8j05rk-Shlley Convex-Concave Mechanical ProsthesIs 

;I ::: BJ15rk-5hiley Monostru\ Mechanical ProstheS1S 

6 '" Carbo Medics Mechanical ProsthesIs 

57::: Carbo-MedIcs Carbo-Sea! Ascefldmg Aortic Valved CondUit Prosthesis 

o Labcor 

o UfeNet 

58 '" Carbo Medics Carbo-Seal Valsalva AscendIng AortiC Valved CondUIt ProstheSIS 

59 '" Carbo Medics Reduced Cuff Aortfc Valve 

60 ::: CarboModlcs Standard Aorbc Valve 

61 '" CarboMedlcs Top-Hat Supra-annular AortiC Valve 

62 '" CarboMedics OptlForm Mitral Vallie 

63 '" CarboMedlcs Standard Mitral Vallie 

64'" CarboMedics Orbis Universal Valve 

65 '" CarboMedics Small Adult Aortic and Mitral Valves 

53 '" Ullehei-Kaster Mechanical ProsthesIs 

10'" MCR! On-X Mechanical ProstheSIS 

8 ::: Medtmnlc-Hell/Hall Easy-Fit Mechanlca! Prosthesis 

108 ::: ATS 3f AortiC Biopmsthesis 

T2 ::: Edwards Pnma Stentiess Porcine Bioprosthesis - Subcomnary 

73 '" Edwards Prima Stentiess Porcine Bloprosthesis • Root 

19'" 81ocor Porcine Biopmsthesls 

74'" Biocor Stentless Porcine Bloprosthesis· Subcoronary 

75 '" Blocor Stentless Porcine Blopmsthesis - Root 

21 '" CarboMedics PhoteFix Pencardial Bloprosthesis 

76 = Carpentier-Edwards Porcine Bioprosthesis 

77 = Edwards Prima Plus Sten~ess Porcine Bloprosthesis - Subcoronary 

78 '" Edwards Prima Plus StenUess Porcine BlOpmsthesls - Root 

22 '" Carpentier-Edwards PERIMOUNT Perlcardlal Bioprosihesis 

© The Society of ThoraCIC Surgeons 2011 Page 6 of 16 

o Medtronic-Hall o Ultracor 

o Mitroflow o Unknown 

o OmniCarbon o Other 

66::: Medlronlc ADVANTAGE Mechanical Prosthesis 

9::: OmniCamon Mechanical ProstheSIS 

54 :: OmniScience Mechanical ProstheSis 

11 :: Sorm Blcamon (BaxLer Mira} Mechanical Prosthesis 

12 = Sorin Monoleaflet Allcarbon Mechanical Prosthesis 

13'" St. Jude Medica! Mechanical Heart Valve 

67 = SL Jude Medical Masters Senes Mechanical Heart Valve 

68:: St, Jude Medica! Masters Senes AortiC Valve Graft ProstheSIS 

69 = SI. Jude Medical Mechanical Heart Valve Hemodynamic Plus (HP) 

Series 

70'" St. Jude Medical Masters Series Hemodynamic Plus Valve with FlexCutf 

Sewing Ring 

71 = Sl. Jude Medical Regent Valve 

14::: Slarr-Edwards Caged-Ball ProstheSIS 

15 = Ultracor Mechanical Prosthesis 

133'" Medtronlc Hall Conduit 

85 "" Medtronlc Contegra Bovme Jugular Bioprosthesis 

37 = Mltroflow Pericardial BJOprosthesis 

39'" SI. Jude Medical TOronto SPV Stentless Porcine Blopmsthcsis 

40::: St. JUde Medlcal-Biolmplanl Porcme B!oprosthesls 

86 = St. Jude Medical Blocer Slented Tissue Valve 

87 '" St. Jude Medical Epic Stented Porcine Bioprosthesis 

88'" St JUde Medical Toronto Root Stentless Porcme Bioprosthesis 

38 :: Sorln Pencarbon Slentiess Pericardlal Bioprosthesls 

111 '" Carpentier-Edwards PERIMOUNT MAGNA Pencardial Bioprosthesis 

With Carpentier-Edwards Thermafix nssue Process 

112 = Carpentier-Edwards PERIMOUNT Theon RSR Pericardiai 
222 


85440.173

103 '" Carpentier-Edwards PERIMOUNT Pencardlal Magna BlOprosthesis 

23 '" Carpentier-Edwards Standard Porcine Bioprosthesis 

25:: Carpentier-Edwards Supra-Annular Aortic PorClOe Bioprosthesls 

79'" Cryolife O'Bnen Stentiess Porcine Bloprosthesis - Subcoronary 

SO '" Cryolife O'Brien Stentless Porcine Bloprosthesl1, - Roo! 

55 '" Hancock Standard Porcine Bioprosthesis 

28 = Hancock II Porcine Bioprosl:hesis 

29 = Hancock Modified Orifice POfCirle SloproslheslS 

30= lonescu-5hileyPericardlalBloprosthesis 

31 = LabcorSlented Porcine Bioprosthesls 

81 '" Labcor Stentless Porcine BlOprostnesls - Subcoronary 

82 = Laboor Stentless ?arcms Bloprosthesls - Root 

83'" Medtronlc Freestyle Stentless Porcine BlOproslhesis - Subcoronary 

84 = Mecrtranlc Freestyle Stenllass Porcine Bloprosthesls - Root 

35 = Medtronlc Intact Porcine Bioproslilesis 

36 ::;; Medlronic Mosaic PorCine Bioprosthesis 

89 = CryolJfe Aortic Homograft 

90 '" CryoUfe Pulmonary Homograft 

91 = CryoLrfe CryoValva SG(Deceliularized)Aortlc Homograft 

92 = CryOlite CryoValve SG Pulmonary Homograft 

41 : HomograftAortic-Subcoronary 

45'" Pulmonary Autograft to aortIC mot (Ross Procedure) 

109 =Al'S Simulus Flex-O Rlrlg 

94 '" CarboMed!cs AnnuloFlo Rmg 

95 ::: CarboMadics AnnuloFlex Ring 

Ring. A.nnuloplasty 

96 -'" CarboMedics CardloFix BoVirle Pericardium With PholoFi)( Technology 

46 '" Carpentier-Edwards Classic Annuloplasty Ring 

104'" Carpentier-Edwards Geoform Ring 

105'" Carpentier-Edwards IMR Etloglx Ring 

47", Carpentier-Edwards Physlo Annuloplasty System Ring 

48 '" Cosgrove-EdWards Annuklplasty System Ring 

97 = Edwards Me' Tricuspid Annuloplasty System 

98 = Genesee SculotorAnnulopiasty Ring 

49 '" Medtromc Sculptor Rlng 

50 '" Medtmmc-Duran AnCora Rmg 

51 = Sonn-PUlg-Messana Ring 

100 = Medlmnic ColVin Galloway Future 8end 

101 "'MedtromcOuranBand 

102 = Medtronic Duren - Ancore Band 

777 = ather 

Band -A.nnuloDlasty 

Bloprosthesls 

113 = Carpentier-EdWards PERIMOUN.T RSR Pencardial Sioproslhesis 

114 = Carpentier-EdWards PERIMOUNT Theon Pencardlal Bioprosihesis 

115 = Carpentier-EdWards SAY. Porcme Bioprosthesls 

116 = Edwards Pnma Plus Stentless Bioprosthesls 

117 = Carpentier-Edwards PERIMOUNT ?jus Perlcardlal Bloproslhesls With 

TncentnxHolder 

118 '" Carpentier-EdWards Durafie)( Low Pressure Porcine BloprosthBsls 

119 = Carpentier-Edwards Duraf1ex Low Pressure ESR Porcine 

BlDproslhesis 

120'" Carpenlier-Edwards PERIMOUNT Theon Perlcardial Sioprosthesls 

with Tncentn)(Holder 

121"" St. Jude Medical Bieeor Supra Slanted Porcine Blopmsthesls 

122 = St. Jude Medical Epic Supra Slanted Porcine B!opmsthes!s. 

134 '" Cerpenlier Edwards Physio II 

135'" Carpentier Edwards Perlmounl Magna Mitral Vulve 

42'" Homograft Aortic - Root 

43 '" Homograft Mitral 

44'" Homograft Pulmonic Root 

93: lifeNet CV Allografts 

52'" SI. Jude Medical SegUin Annuloplasty Ring, 

106 '" St Jude Medical Rigid Saddle Ring 

99'" SI. Jude Medical Tailor Annu!oplasty Ring 

123 = ATS Simulus F~xibls Annuloplasty flng. 

124'" ATS Simulus SemI-Rigid Annuloplasty ring 

125 = Carpentier-EdWards CIElsSIC Annuloplasty Ring With Duraflo Treatment 

126'" Carpentier-Edwards Physio Annuloplasty Ring with Duraflo Treatment 

127 = Cosgrove-Edwards Annuloplasty System with Duraflo Treatment 

128'" Myxo Etlogix Annuloplasty Rlflg 

131 =Sann Memo 3D Ring 

132 = UNIRING, Universal Annuloplasty System 

137'" Medtronlc ColVin Galloway Future Ring 

138= MedlronlcProfile 3D Ring 

107'" S1. Jude Medical Tailor Annuloplasty Band 

110'" ATS Simulus Fle)(-C Band 

VAD Implanted or Removed: 0 No 0 Yes, implanted 0 Yes, explanted 0 Yes, implanted and explanted (If "Yes" complete Section L) 

VAOProc 2480) 

g~e~a?:~~~~~trocedure: 0 Yes 0 No (If 'Yes" complete SectIOn M) 

Other Non-Cardiac Procedure: 0 Yes 0 No tlf 'Yes" complete Secbon N) 

OnONCard (2500 

Unplanned 0 No 

Procedure: 0 Yes, unsuspected patient disease or anatomy 

UnplProc 0 Yes, surgical complication 

(2501) 

Unplanned CABG: 0 Yes 0 No UnplCABG (2502) 

Unplanned Aonic Valve Procedure: 0 Yes 0 No UnplAV (2503) 

Unplanned Mitra! Valve Procedure: 0 Yes 0 No UnplMV (2504) 

Unplanned Aorta Procedure: 0 Yes 0 No UnplAo (2505} 

Unplanned VAD Insertion: 0 Yes 0 No UnpJVAD (2506) 

Un lanned Other Procedure: 0 Yes 0 No Un 10th (2507) 

Enter up to 10 CPT·1 Codes pertaining to the surgery for which the data collection form was initiated: 

,:;,~ ~;~;~t'''''' 2pTl.caoe:: 

(252m ~P71C()Od W:;30 ;;..~ ~;~~~~~u"" ~~~~~~,u"'".' 

~;..~ ~;~~A;' ;~;<;;~~' ~)';,~~~ ~~~ ~9~~~~ ;-::",;,~';' 

OR Entr Date And Time: ORErlcyDT (2610) c.m : ',:, . 'Onceh 

OR Exit Date And Time: ORExltDT 2620) j :m'" ad ,'"iVY hi' W;l· :.{ "f Lb>.' 

Initial 

Initial 

Intubation 

Extubation 

Date 

Date 

and 

and 

Time: 

Time: 

IntubateDT 

ExtubateDT(2680} 

2670) I 

I I 

, ,mr-; 

.~,mj:J 

j~ 

i r~m:,l' !..'rcnrJ. 

Skin 

Skin Incision 

Incision 

Stop 

Start 

Date 

Date 

and 

and 

Time: 

Time: 

SIStopDT 

SIStartDT (2690) 

2700 I I 

/ I 

.1l1~,:::d 

·'llr, ,~,.'! 

'.1'\'\ 

~ 

!"J' m""" . 24 '11 ciJc>; 

Appropriate Antibiotic Selection: I Appro. p.riate Antibiotic Administration Timing: I Appropriate Antibiotic Discontinuation: 

DYes 0 No 0 Exclusion 0 Yes 0 No 0 Exclusion 0 Yes 0 No 0 Exclusion 

AbxSeiect 2710 AbxTIff\ln (2720 AbxDISC 2730 

CPB Utilization: ~D~N~o!,!n=e==+_==,-_________________________ -I CPBUtil (2740) I 0 Combination I ... :c,' ':".,,' 

Combination Plan: 0 Planned 

© The Society ofThoracjc Surgeons 2011 Page 7 of 15 
223 


85440.174

CPBCmb (2750) o Unplanned 

Reason: CPBCmbR (2760) 

o Exposure/visualization 

o Bleeding 

o Inadequate size and/or diffuse disease of distal vessel 

o Hemodynamic instability (hypotension/arrhythmias) 

D Conduit quality and/or trauma 

DOther 

DFull 

ca~~~~~'~~'~on~~I'BypaSS Time (minutes): PerfusTm (2770) 

Lowest Temperature (0 C): ____ Lw-'t=Te-m-p-'(2"":::80::7)--

Lowest Hematocrit: ____ LwstHct (2790) 

Arterial Cannulation Site: 

Aortic 0 Yes 0 No CanArtStAort (2851) 

Femoral 

Venous Cannulation Site: 

Circulatory Arrest 0 Yes 0 No ,{" 1"25 ' CircArr (2865) 

Femoral 

Jugular 

Right Atrial 

Left Atrial 

DYes DNa CanArtStFem (2852) 

DYes DNa CanVenStFcm (2856) 

DYes D No CanVenStJug (2857) 

DYes D No 

CanVenStRtA (2858) 

~a~~~n~t~f~ 2859) 

Circulatory Arrest Without Cerebral Perfusion Time: ~_ (min) DHCATm (2866) 

Circulatory Arrest With Cerebral Perfusion: DYes D No CPerlUtll (2867) 

Cerebral Perfusion Time: (min) CPertTime (2868) 

Axillary 

Other 

Pulmonary Vein 

Caval/Bicaval 

Other 

DYes 0 No CanAnStAx (2B53) 

DYes DNa CanArtStOth (2854) 

DYes DNo CanVenStPulm (2861) 

DYes D No CanVenStBi (2862) 

DYes DNo CanVenSIOth (2863) 

Cerebral Perfusion Type: D Antegrade D RetrQ9rade D Both antE!grade and retroarade CPertTvp (2869 

Aortic Occlusion: D None - beating heart 

AortOcd (2870) D None - fibriUating heart 

~ ~~~~~~~~~~~i~~ ~d,'u'~n ,"~"."~ Cross Cla~&:~~~~ ~(2~88~O-:) _~ (min) 

Cardioplegia Delivery: CplegiaDeliv (2900) 0 None D Antegrade 0 Retrograde DBoth 

1'"!,ntcr""C!s' '::;e!':,:'a~-s ')('3:111""" i Tvoe of cardiooleaia used: 0 Blood 0 Crvstailoid D Both D Other Cple iaTvpe (2901) 

Cerebral Oximetry Used: 0 Yes 0 No. I'"\::s . CerOxUsed (2930) 

Pre·tnduction Basellne Regional Oxygen Saturation: Left: ~_ (%) Right: ~_ (%) 

PreRS02Lft (2940) PreRS02Rt (2950) 

Cumulative Saturation Below Threshold: Left: __ (min ~%) Right: _~ (min -%) 

CumulSatLft (2960) CumulSatRt (2970) 

Cerebral Oximeter Provided First Indication: DYes 0 No COFlfstlnd (2980) 

Skin Closure Regional Oxygen Saturation: Left: ____ (%) Right: ~_ (%) 

SCRS02Lft 2990 SCRS02Rt (3000 

Concentric Calcification: 0 Yes D No ConCalc (3005) 

Echo Assessment of Ascending Aorta/Arch: DYes 0 No ,AsmtAscM (3010) 

Assessment of Aorta Disease: D Normal Aorta 

AsmtAoDx (3020) D Protruding Atheroma < 5 mm 

D Mobile plaques 

Assessment Altered Plan: 0 Yes 0 No AsmtAPln (3030) 

IntraoD Blood Products Used: 0 Yes 0 No IBldProd 3040) 

D Extensive intimal thickening 

o Protruding Atheroma >= 5 mm 

o Not documented 

-!-L IntraoD 8100d Products Refused: 0 Yes 0 No 181dProdRef (3050 

. \ ('t Red Blood Cell Units: _~ IBdRBCU (3060) 

Fresh Frozen Plasma Units: ___ IBdFFPU (3070) 

CryopreCipitate Units: ~~_lBdCryoU (3080) 

Platelet Units: ~_~ IBdPlatU (3090) 

Factor Vila: IBdFactorVl1 (3091) 

Intraop Antifibrinolytic Medications: ~:~~~c~~~~~~?aprOiC Acid: 0 Yes D No ~~:~~~~~~~~~id: DYes 0 No 

intraoperative TEE Performed post procedure: 0 Yes 0 No_ ~ 'iss ,lnOpTEE {3157) 

Highest leve! aortic insufficiency found: 0 None 0 Trace/trivial D MUd D Moderate D Severe PRepAR (3158) 

Highest level mitral insufficiency found: 0 None 0 Trace/trivial 0 MUd D Moderate D Severe PRepMR (3159) 

Highest leve! tricuspid insufficiency found: D None D Trace/trivial 0 Mild D Moderate D Severe PRepTR (3161) 

© The Soc!ety of ThoraCIC Surgeons 2011 Page 8 of 16 
224 


85440.175

J. Coronary Bvpass (If 0 CAB-Yes) 

Hybrid ~~~~~r~ ~~!~~~ ~~In~~~~~~ed~ ~~~~d~ ~~gl~~e5 DC~~~'~~~;~ (~~~;~tal (3170) 

PCI Procedure Performed: D Angloplasty D Stent HybrProc (3180) 

Number of Distal Anastomoses with Arterial Conduits: D1StArt (3190 

Number of Distal Anastomoses with Venous Conduits: ___ ,Ii >:J ' DistVeln (3200) 

Vein Harvest Technique: 0 Endoscopic 0 Direct Vision (open) 0 Both D Cryopreserved DlstVemHTech (3205) 

C'1:€2' ,'5':r- ,:ll'< _, Saphenous Vein Harvest Time: ___ (minutes) SaphHrvstT (3206) 

Saphenous Vein Preparation Time: _ (minutes) SaphPrepT (3207) 

Internal Mammary Artery used for Grafts: 0 Left IMA 0 Riaht IMA 0 Both !MAs 0 No IMA IMAArtUs 3210) 

,I' f~;) ,Ill.:: Indicate Primary Reason: 0 The !MA is not a suitable conduit due to size or flow 

No!MARsn (3220) D Subclavian stenosis 

D Previous cardiac or thoracic surgery 

D Previous mediastinal radiation 

D Emergent or salvage procedure 

o No LAD disease 

Tota! # of Distal Anastomoses done using IMA grafts: 

NumlMADA (3230) 

IMA Harvest Technique: D Direct Vision (open) 0 Thoracoscopy 

IMATechn (3240) 0 Combination 0 Robotic Assist 

Number of Radial Arteries Used for Grafts: ____ :1: >:] ,NumRadArtUs (3260) 

Number of Radial Artery Distal Anastomoses: ____ NumRadOA (3270) 

Radial Distal Anastomoses Harvest Technique: D Endoscopic 0 Direct Vision (open) 0 Both RadHTech (3280) 

::~::: ~~:~ ~~;:~tT~~~ime: _ _ (~i{~~~~:S)d~~~~~e~~~~i86) Number Other Arterial Distal Anastomoses Used other than radial or IMA : NumOArtD (3300) 

© The Society of Thoracic Surgeons 2011 Page 9 of 16 
225 


85440.176

Native Coronary Disease Location Kev: 

4= Distal LAD 7=Circumnex 10=OM3 13:: 

5=Dia anal 1 a-OM1 11 = RCA 14= 

6=Dia onal2 9=OM2 12 PDA 15: 

For each question, check the one choice that aDpiies for each raft 

CABGNUMBER 1 2 3 4 5 6 7 8 9 10 

GRAFT Yes CAB02-10 Nt, 3440 3530 3620 3710 3800 3890 3980 4070 4160 

DONE No 

~~bYs~o~g~~~RY DISEASE LOCATION (See key above) 3355 3445 3535 3625 3715 3805 3895 3985 4075 4165 

HIGHEST PERCENT STENOSIS IN NATIVE VESSEL 

CABPctSten 01-10 3356 3446 3536 3626 3716 3806 3896 3986 4076 4166 

Yes - Diseased CABPrevCon 01-10 3357 3447 3537 3627 3717 3807 3897 3987 4077 4167 

PREVIOUS Yes - No disease 

CONDUIT No orevious conduit 

In Situ Mammary CABProxima!Sile 01" 10 3360 3450 3540 3630 3720 3810 3900 3990 4080 4170 

w Ascendinq aorta .... Descendino aorta iii 

--' Subclavian artery « 

:; Innominate artery 

§ T-araft aff SVG 

'" T- raft off Radial 

0- T-graft off LIMA 

T-araft off RIMA 

i~ In Situ Mammary CABProxTech 01-10 3370 3460 3550 3640 3730 3820 3910 4000 4090 4180 

Runn!nQ 

§~ lnterruoted 

Anastomotic Device 

!f~ Anastomotic Assist Device 

Vein raft CABConduit 01-10 3380 3470 3560 3650 3740 3830 3920 4010 4100 4190 

t:: In Situ LIMA ::J 

C In Situ RIMA 

z Free IMA 0 

() Radial artery 

Other arteries, homograft 

Ri ht Coronary RCA CABDlstSite 01~10 339=1= 3570 3660 3750 3840 3930 4020 4110 4200 

Acute Marainal AM 

w Posterior Descendin Artery ,PDA 

t:: Posterolateral Branch PLB r/) 

z Proximal lAD 

~ Mid LAD 

'" Distal LAD w 

r/) DiaQonal1 

<!: Diagonal 2 

~ Ramus 

!Il Obtuse Mar ina! 1 

C Obtuse Mar ina! 2 

Obtuse Mar 1nal3 

Other 

w Runnina CABDistTech 01·10 3400 3490 3580 3670 3760 3850 3940 4030 4120 4210 

ct~ Interrupted 

>-z Clips 

5~ Anastomotic device 

.... DISTAL End to Side CABDistPos 01·10 3410 3500 3590 3680 3770 3860 3950 4040 4130 4220 

POSITION Seauential side to side 

ENDARTERECTOMY YesCABEndArt 01-10 3420 3510 3600 3690 3780 3870 3960 4050 4140 4230 

No 

J:>CDc:C No CABHvPCI01·10 3430 3520 3610 3700 3790 3880 3970 I 4060 4150 4240 

AnQio lasty r 

© The Society of Thoracic Surgeoos 2011 Page 10 of is 
226 


85440.177

I Slenl 

K. Valve Surcery (If Valve Sur erv-Yes 1 

Aortic Valve Procedure Performed: 0 Yes D No VSAV (4270) 

Procedure Performed: 

VSAVPr (4280)' 

o Replacement 

o Repair I Reconstruction 

Primary Repair Type: 38,;;:t ;0\1 :f'?1 8:1::11'" 

Commissural Annuloplasty 0 Yes 0 No 

VSAVRComA (4282) 

Leaflet plication DYes 0 No VSAVRLPlic (4284) 

Leaflet free edge reinforcement (PTFE) 0 Yes 0 No VS.!\,VRPTFE (4286) 

Leaflet commissura! resuspension suture DYes 0 No 

VSAVRComRS (4288) 

Division of fused leaf!et raphe DYes 0 No 

VSAVRRaphe (4290) 

o Root Reconstruction with valved conduit 

o Replacement and insertion aortic non-valved conduit 

o ResLlspenslon AV without replacement of ascending aorta 

o Resuspenston AV With repl()cement of ascending aorta 

o Aplco-aortic oonduft (Aortic va\ve bypassj 

o Autograft with pulmonary valve-Ross procedure 

o Homograft 

o Valve spanng root reimplantation (David) 

o Valve spanng root remodeling (Yacoub) 

Transcatheter Valve Rep!acement: 0 Yes D No VSTCV (4295) 

Ring Annuloplasty DYes 0 No 

VSAVRRlngA (4283) 

Leaflet resection suture 0 Yes D No 

VSAVRLResect (4285) 

Leaflet pericardial patch 0 Yes D No VSAVRLPPatch (4287) 

Leaflet debridement 0 Yes 0 No 

VSAVRDeb (4289) 

, Rep!acement approach: D Transapica! 0 Transaxillary 0 Transfemoral VSTCVR (4300) 

Aortic Annular Enlargement DYes 0 No AnlrEnl (4310) 

Resection of sub~aortic stenosis: DYes 0 No ResectSubA (4311) 

0~~~I~t ~:oel Number :--------- ~~:;lm-s~z~4703C740~-

Mitral Valve Procedure Perlormed: 0 Yes D No VSMV (4351) 

Procedure Performed: VSMVPr (4352) 

o Repair 

i: [\0:},:1' Repair Type: ·Sdi.' t 2'1 t~,a~ a,'piy, , 

Annuloplasty 0 Yes D No VSMltRAnnulo (4361) 

Leaflet Resection DYes 0 No 

VSMitRLeafRes (4362) Resection Type: 0 Triangular OOuadrangular 0 Other 

VSLeafResTyp (4380) 

Sliding Plasty 

VSMitRSlidP (4391) 

Annular decalcification 

VSMltRADecaic (4393) 

Neochords (PTFE) 

VSMltRPTFE (4394) 

DYes 0 No 

DYes 0 No 

DYes ONo 

ChordalfLeaflet transfer DYes 0 No VSMltRChord (4401) 

Leaflet extension/replacement/patch DYes 0 No 

VSMitRLeafERP (4402) 

Edge to Edge Repair DYes D No VSMltREdge (4403) 

Mitral commissurotomy 0 Yes 0 No 

VSMitRMrtComm (4404) 

Location: 0 Anterior 0 Posterior 0 Both Anterior and Posterior 

VSLeafRepLoc (4390) 

o Replacement ';;:Si):2:c:~'C',t, Repair attempted prior to Mitral Valve Replacement 0 Yes 0 No 

Mitraltntent (4410) 

~~~~t (~4~~~1 Number; ~~~i:lm::-;S'='''14C;44:;CO;;-) -

Mitral Chords Preserved: 0 None OAnterlor 0 Posterior 0 Both VSChorPres (44S0) 

© The Society of Thoracic Surgeons 2011 Page 11 of16 
227 


85440.178

Tricuspid Valve Procedure Perfonned:OpTricus (4500) 

o No 

o Annuloplasty only 

o Replacement 

o Reconstruction with Annuloplasty 

o Reconstruction without Annuloplasty 

o Valvectomy 

~~~~~~t ~~~~I Number: _______ _ 

Pulmonic Valve Procedure Performed: OpPulrr. (4560) 

o No 

o Replacement 

o Reconstruction 

o Valvectomy 

~~~I~~ ~~:O~I Number: 

L. Mechanical Cardiac Assist Devices 

1'"[."·'JI:!;:','y, 

Type of Annuloplasty: 0 Pericardium 

OpTricusAnTy (4510) 

Size: 

VSPulmSz 4590 

Intra Aortic Salloon Pump (IASP): 0 Yes 0 No !, y,,, IABP (4610) 

IABP Insertion: 0 Preop 0 Intraop 0 Postop IABPWhen (4620) 

Primary Reason for Insertion: 0 Hemodyn Instability 0 PTCA Support 0 Unstable Angina 

o CPB Weaning Failure 0 Prophylactic 

Catheter Based Assist Device Used: 0 Yes 0 No ~':'r;s CathBasAssist (4660) 

Device: 0 Impella 0 Tandem Heart 0 Other CathBasAssistDev (4670) 

When inserted: 0 Preop 0 Intraop 0 Postop CathBasAssistWhen (4690) 

o Prosthetic Ring 

Primary Reason for Insertion: 0 Hemodynamic Instability 0 CPB weaning failure 0 PCI failure 0 Other CathBasAssistlnd (4700) 

g:t~eB~::~~~t~:~g:~~:1Q\ _1- _I _____ 'I"rll OJ ).,'i \ 

Extracorporeal Membrane Oxygenation (ECMO): 0 Yes 0 No :I'les ,ECMO (4730) 

ECMO Initiated: 0 Preop 0 Intraop 0 Postop 0 Non-operative ECMOWhen (4740) 

Clinical Indication for ECMO Placement 0 Cardiac Failure 0 Respiratory Failure 0 Hypothermia 0 Rescue/salvage 

ECMOlnd (4750) 

Previous VAO: 0 Yes 0 No :.Y&S PrevVAD (4760) 

Implanted at another facility: 0 Yes 0 No PrevVADF (4770) 

Prey VAD Insertion Date: I / ''TIm JJ '\\') , PrevVADD (4771) 

Prev VAD Indication: DBlidge tOTransPlar:rtatiOn-0 Bridge to Recovery 0 Destination 0 Post Cardiotomy Ventricular failure 

PrevVADln (4772) 0 Device Malfunction 0 End of Ufe 

Prey VAD Type: 0 RVAD 0 LVAD 0 BiVAD 0 TAH 

Prey VAD Device: "f"," ,",'c"1 C'-J,'e-, "",ee l"'~ PrevVADDev;ce (4774 

(lfVAO implantec or Removed.) 

Refet"ences to 'Initial VAD" refer to the Initial VAD for thIs hospItalization, not a V}\O placec durmg a prevIous hOspitalization 

VAD Implant Type: Right VAD (RVAD) Left VAD (LVAD) 

Biventricular VAD (B/VAD) Total Artifidal Heart (TAH) 

VADDevice: J'"l J8"'8~:: JUI~~ :"'S~;;" jOGL' '(Tt) 

Explant Reason: 1. Cardiac Transplant 2, Recovery 3. Device Transfer 4. Device-Related Infection 

5. Device Malfunction 6. End of Life 

Indication for this VAD: 0 Bridge to Transplantation 0 Bridge to Recovery 0 Destination 

VADlnd (4790) 0 Postcardiotomy Ventricular Failure 0 Device Malfunction 0 End of Ufe 

tnrusllmplant Data 

Implant Type VAD Device Implant Dat~ ~ Explant Date EXQ:lant ReasoD 

_'_I __ DYes DNa I I 

mm dd yyyy mm dd :;:;yy- VlmpTy (4850) VProdTy (4880) V!mpOt (4890) VExp (4900) VExpDI (4910) VExpRsn (4920) 

AdditiQnii!:llm~§nt(§): Qi;!ta 

Second Device Implanted: DYes 0 No Vlmp2 (4940) 

ImQlsot I~l2e#2 VAD pevice #2 Im2J~nt Date#2 ElIDlant#2 Exg:!ant Date#2 EXQ:!§nt R~asonlt2 

~'~'-- DYes DNa 

mm dd yyyy -'-'-- mm dd yyyy 

VimpTy2 (4950) VProdTy2 (4980) VlmpDt2 (4990) VExp2 (5000) VExpOt2 (5010) VExpRsn2 (5020) 

©The Society of Thoracic Surgeons 2011 Page 12 of 16 

Transplant Date 

-'-'-- mm dd yyyy VTxDt (4930) 

TraosQlant Qate#2 _'_1_-

mm dd yyyy 

VTxOt2 (5030) 
228 


85440.179

Third Device Implanted: DYes D No ' Vlmp3 (5040) 

Imglant T:me#3 VAD Device #3 Implant Date#3 Explant#3 Explant Date#3 Explant Reason#3 

---- ---- I I DYes DNa I I 

mm dd yyyy mm dd yyyy 

VimpTy3 (5050) VPmdTy3 (5080) VimpDt3 (5090) VExp3 (5100) VExpDt3 (5110) VExpRsn3 (5120) 

Primary VAD Complications Data: 

Intracranial Bleed DYes 0 No 

PVCmpBld (5140) 

Embolic Stroke 0 Yes D No 

PVCmpESt (5150) 

Drive!ine and/or cannula Infection DYes D No 

PVCmpDCI (5160) 

Pump Pocket Infection DYes D No 

PVCmpPPI (5170) 

Endocarditis DYes 0 No 

PVCmpEnd (5180) 

Device Malfunction DYes 0 No 

PVCmpMal (5190) 

Hemolysis 0 Yes D No 

PVCmpHem (5191) 

Bowel Obstruction DYes D No 

PVCmpBO (5200) 

Addlhonal Compllc<.lhonS (not sf1eciflc to Initial VAD as above) to be collected in Postoperative Events section 

VAD Discharge Status: 

VADD!scS (5210) 

M, O~rCarowcP~um 

(If Other Card'" Yes 

o With VAD 

D WithoutVAD 

D Expired in Hospital 

Left Ventricular Aneu sm Re air: 0 Yes 0 No OCarLVA (5220 

Ventricular Septal Defect Repair: 0 Yes 0 No OCarVSD (5230) 

Atrial Septal Defect Repair: 

Transplant Date#3 

I I 

m;:;:; dd yy::;;;- VTxDt3 (5130) 

o Sinus Venosus 0 PFO OCarASDT 5241) 

Sur ica! Ventricular Restoration: 

Congenital Defect Repair: 

Congenital Diagnoses: Select up to three most significant diagnoses: 

Diagnosis 1: _____ Diagnosis 2: ___ _ 

OCarCongDlag1 (5310) OCarCongD18g2 (5320) O~;":':,~~[)i~;':,;;:;: Congenital Procedures: Select up to three most significant 

Procedure Procedure 2: Procedure 3: 

OCarCon roc~ OCarCon Proc~ 

~:~~:C ~~~~:~ Laser ~~O~C~~~'T~~m~e:~(~;;~~~o~t~O~ca~'L~a~SC~(5~3~70~================================1 Cardiac Trans lant: DYes 0 No OCarCrTx 5390 

Arrhythmia Correction Surgery: 0 None 0 Permanent Pacemaker 

OCarACD (5400) D Permanent Pacemaker with Cardiac Resynchronization Technique (CRT) 

D Implantable Cardioverter Defibrillator (ICO) D ICD with CRT 

) Arrh hmia Correction Sur e Lead Insertion or Re lacement: 0 Yes 0 No OCarACOLI (5410) 

Arrh hmia Correction Sur e Lead Extraction: 0 Yes 0 No OCarACDlE (5430 

Atria! Fibrillation Surgical Procedure: 0 Yes 0 No OCarAFlbSur (5450) 

Surgical Procedure Location: D Biatrial D Left atrial only D Right atrial only OCarAFibSurLoc (5451) 

Left Atrial Appendage Obliterated DYes D No OCarAFibSurLAA (5452) 

Method of Lesion Creation: 

Radio frequency DYes D No 

OCarAFlbMethRad 

Ultrasound 

(5455) 

DYes 0 No 

OCarAFlbMethUltra 

(5456) 

Cryo 

Microwave 

Atria! Fibrillation Ablation Procedure: OCarAFibAProc (5465) 

DYes DNa 

OCarAFlbMethCryo 

(5457) 

OYes D No 

OCBrAFlbMethMicro 

(S458) 

Laser DYes D No 

OCarAFibMethLas 

(5459) 

DYes 0 No 

OCarAFlbMethCAS 

(5460) 

o Primarily epicardia! procedure (e.g., pulmonary vein isolation with or without connection to left atrial appendage), 

D Primaril intracardiac rocedure (e.g., Maze procedures; lesions to mitra! annulus; etc.) 

Aortic Procedure Type: OCAoProcType (5471) 

© The Society of Tlloradc Surgeons 2011 Page 13 of 16 
229 


85440.180

o None 

o Aneurysm . "1 CJ:')'~''1 

Aortic Root 0 Yes 0 No ONCAoRt (5473) 

Dacron graft used: 0 Yes 0 No ONCAoGraft (5474) 

Repair of ascending aortic aneurysm: 0 Yes 0 No ONCAse (5480) 

Repair of aneurysm in the arch of the aorta: 0 Yes 0 No ONCArch (5490) 

Extent of repair: 0 Hemj-arch 0 Total arch ONCArchRepExt (5491) 

Repair of a descending aortic aneurysm: 0 Yes 0 No ONCDesc (5500) 

Repair of a thoracoabdominal aneurysm: 0 Yes 0 No ONCThAbd (5510) 

Graft replacement used: 0 Yes 0 No ONCThAbdGraft (5511) 

Intercostal vessels re-implanted: 0 Yes 0 No ONCThAbdlnterVes (5512) 

CSF drainage utilized: 0 Yes 0 No ONCThAbdLumCSF (5513) 

Extent of descending aorta replacement: ONCThAbdExtent (55-14) 

o Proximal 0 Mid 0 Distal 

o Proximal - Mid 

o Proximal - Mid - Distal 

o Mid - Distal 

o Dissection 

(including 

intramural 

hematoma) 

~~~i~l~i~section is acute: 0 Yes 0 No AoDlsAe (5516) 

Dissection type: 0 Stanford Type A 0 Stanford Type B AoDlsTyp (5517) 

o Trauma ,Aortic Trauma type: 0 Blunt 0 Penetrating AoTrTyp (5518) 

o Coarctation 

o Other 

Endovascular Procedure (TEVAR): 0 Yes 0 No EndoProc (5520) 

I''!es Endovascular Debranching: 0 Yes 0 No EndoProeDeb (5521) 

Tumor Resection: 0 None 0 Mvxoma 0 Fibroelastoma 0 Hypernephroma 0 Sarcoma 0 Other OCTumor (5530) 

Pulmonary Thromboembolectomy: 0 None 0 Yes Acute 0 Yes, Chronic OCPulThromDis (5540) 

Other: 0 Yes 0 No OCarOlhr (5550) 

N. Other Non Cardiac Procedures 

::: Yes) 

Carotid Endarterectom : 0 Yes 0 No ONCCarEn (5560) 

Other Vascular: 0 Yes 0 No ONCOVasc (5570) 

Other Thoracic: 0 Yes 0 No ONCOThor (5580 

Other: 0 Yes 0 No ONCOther (5590) 

O. Post Operative 

Postoperative Creatinine Level: _________ PostCreal (5610) 

Blood Products Used Postoperatively: 0 Yes 0 No .1' l'e2 BldProd (5620) 

Red Blood Cell Units: Fresh Frozen Plasma Units: Cryoprecipitate Units: __ Platelet Units: 

BdRBCU 5630 BdFFPU 5640 BdCryoU 5650 BdPlatU (5660) 

Extubated in OR: 0 Yes 0 No ExtubOR (5670) 

~:~~u~~~ci~g) During Hospital Stay: 0 Yes 0 No 1 Ad~i!i~~~!~(~~~0~8ntilated: ____ _ 

leu Visit 0 Yes 0 No ICUVISlt (5700) ; ";:':= 1 Initial leu Hours: ICUlnHrs (5710 

Readmission to ICU: 0 Yes 0 No ICUReadm (5720) .IiYs's . AdditionallCU Hours: ICUAdHrs (5730) 

Post Op Echo Performed: 0 Yes 0 No ," .'9.~ POpTTEch (S744) 

Highest leve! aortic insufficiency found: 0 None 0 Trace/trivial 0 Mild 0 Moderate 0 Severe POpTTAR (5745) 

Highest leve! mitral insufficiency found: 0 None 0 Traceltrivial 0 Mild 0 Moderate 0 Severe POpTTMR (5746) 

Highest leve! tricuspid insufficiency found: 0 None 0 Trace/trivial 0 Mild 0 Moderate 0 Severe POpTTTR (5747) 

Post Op Ejection Fraction Done: 0 Yes 0 No I' . C~ POpEFD (5748) 

Post Op E'ection Fraction: _ (%) POpEF (5749 

~~~~~;D~;:mes (biomarkers) Drawn: 0 Yes 0 No I' 'l'h ':~~~k~~~~: ~ ~~~~{~~~;~~) 1-_ ~~~~~{~~~i~3; __ _ 

12-Lead EK 0 Not erformed 0 No si nificant chan es 0 New Patholo ical Q-wave or LBB8 POpEKG (5754) 

I Imaging Stu : POplmagStdy (575-5) 

I 

0 Not performed 

o AngiogrBphic evidence of neW thrombosis or occlusion of graft or native coronary 

o Imaging evidence of new loss of viable myocardium 

o No evidence of new myocardial in'ury 

P. Postoperative Events 

In H~::t~stoperative Event Occurred: 0 Yes 0 No \' '1 SS Complies (57S9) 

ReOp for Bleeding !Tamponade: 0 Yes 0 No COpRe81d (5760) :. : Bleed Timing: 0 Acute 0 Late COpReBldTim (5770) 

ReOp for Valvular Dysfunction: 0 YeS 0 No COpReVlv (5780) 

© The Society of Thoracic Surgeons 2011 Page 14 of 16 
230 


85440.181

ReOp for Graft Occlusion: 0 Yes 0 No COpRcGft (5790) 

ReOp for Other Cardiac Reasons: 0 Yes 0 No COpReOth (5800) 

ReOp for Other Non-Cardiac Reasons: 0 Yes 0 No COpReNon (5810) 

Open chest with planned delayed sternal closure: 0 Yes 0 No COpPlndDelay (5811) 

~ 

Sternotomy Issue: 0 Yes 0 No CStemal (5830) I' ') cs Sternal instabilit !dehlscence (sterile): 0 Yes 0 No CSternalDehls (5840) 

(see CDC definitions in training manual) 

Surgical Site Infection: 0 Yes 0 No I' '< s" SurSJnf (5841) 

Stema! Superficial Wound Infection: 0 Yes 0 No CSternalSuplnf (5850) 

Deep Sternal Infection: 0 Yes 0 No C!StDeep (5860) 

Mediastinitis: 0 Yes 0 No ' CSternalMedla (5870) 

Diagnosis Date: _.....J _-..-I _______ ",'\. CStemalMediaDIDiag (5880) 

Secondary Procedure Open with Packing/Irrigation: 0 Yes 0 No CSterna!MediaSPOpen (5890) 

Secondary Procedure Wound Vac: 0 Yes 0 No CSternalMedlaSPWVac (5900) 

Secondary Procedure Muscle Flap: 0 Yes 0 No CSternalMedlaSPMuscie (5910) 

Secondary procedure Omental Flap: 0 Yes 0 No CSIernalMedla8POmentai (5920) 

Thoracotomy: 0 Yes 0 No C!Thor (5930) 

Conduit Harvest or Carmutation Site: 0 Yes 0 No CILeg (5940) 

Wound Intervention - Open with Packing/Irrigation: 0 Yes 0 No WndlntOpen (5960) 

Wound Intervention - Wound Vac - 0 Yes 0 No WndlntWVac (5970) 

Sepsis: 0 Yes 0 No CSepsis (6010) i ... '(,~ : Positive Blood Cultures: 0 Yes 0 No CSeosisPBC (6020 

Neurologic 

Postoperative Stroke (Perm>24 hours): 0 Yes 0 No CNStrokP (6030) 

Transient Ischemic Attack (TIA): 0 Yes 0 No CNStrokTTIA (6040) 

Encephalopathy: 0 None o Anoxic o Embolic D Drug o Metabolic o Intracranial Bleeding o Other 

CNComaEnceph (6070) 

Para! sis: 0 Yes 0 No CNPara! (6110) ," '2~ Paralysis Tvoe: 0 Transient D PermanentCNParalTv (6120) 

~ 

Prolonged Ventilation: 0 Yes 0 No CPVntLng (6130) 

Pneumonia: 0 Yes 0 No CPPneum (6150) 

Venous Thromboembolism - VTE: 0 Yes 0 No CVTE (6160) 

Pulmonary Thromboembolism: 0 Yes 0 No Pu!mEmb (6170) 

Deep Venous Thrombosis: 0 Yes 0 No DVT (6180) 

Pleural Effusion Requirinq DrainaQe: 0 Yes 0 No CPIEff (6190) 

Boom 

Renal Failure: 0 Yes 0 No CRenFaill6200 

Dialysis (Newly Required): 0 Yes 0 No ) Required after Hospital Discharge: DYes 0 No 

CRenOla! (6210) Dia!Dur(6220) 

Ultra Filtration Required: 0 Yes 0 No CUltraFiJ 6230) 

Vascular 

lliacJFemora! Dissection: 0 Yes 0 No CVallFem (6240) 

Acute Limb Ischemia: 0 Yes 0 No CYaLblsc (6250) 

Othe, 

Rhythm Disturbance Requiring Permanent Device: 0 Pacemaker DieD o Pacemaker/!CD o None CRhythmDis (6270) 

Cardiac Arrest 0 Yes 0 No COtArrst (6280) 

Anticoagulant Event: 0 Yes 0 No COICoag (6290) 

Tamponade (Non~Surgicallntervention): 0 Yes 0 No COITamp (6300) 

Gastro-lntestinaJ Event: 0 Yes 0 No COtGI (6310) 

Multi-System Failure: 0 Yes 0 No COtMSF (6320) 

Atrial Fibrillation: 0 Yes 0 No C01AFIb (6330) 

Aortic Dissection: 0 Yes 0 No CVaAoDts (6340) 

Recurrent Laryngeal Nerve Injury: 0 Yes 0 No RecLarynNrvlnj (6341) 

Phrenic Nerve Injury: 0 Yes 0 No PhmnNrvlnJ (6342) 

Other: 0 Yes 0 No COtOlher (6350) 

Q.Mortality 

~~~~:~~~~oies 0 No I ~:~~~~~e6~;~~us: 0 Alive DDead ! Status at 30 days After Surgery: 0 Allve DDead o Unknown 

Mt30Stai 6380) 

Primary method used to verify 30-day status: Mt30StatMeth (6381) 

o Phone cal! to patient or fa mHy o Evidence of life in medical record o Sodal Security Death Master File 

o Letter from medical provider o Office visit to surgeon >::: 30 d~ after procedure DOther "rO!3:(,' ='(,,, Operative Death: 0 Yes 0 No MtOpD (6390) 

Mortality~ Date __ 1 __ / ____ MtDate (6400) 

Location of Death: o OR During Initial Surgery 0 Hospital (Other than OR) o Home o Extended Care Facility 

MtLor.aln (6410) o Hospice o Acute Rehabilitation o OR During Reoperation o Unknown o Other 

Primary Cause of Death MtCause (6420) 

o Cardiac o NeuroloQic o Renal o Vascular o Infection o Pulmonarv 0 Valvular o Unknown DOthe, 

© The Society of Thoracic Surgeons 2011 Page 150f16 
231 


85440.182

R. Discharge 

ADP Inhibitors: DYes 0 No "ADP (6430) 

~rn. DYes 0 No :Mehy (6440) 

DYes 0 No o Contraindicated DCASA 6460 

DYes o No, contraindicated o No not indicated DCACE (6470) 

Beta Blockers: DYes D No o Contraindicated DCBeta (6480) 

Lipid Lowering: DYes D No o Contraindicated i'ss aStat!n o Non Statin DBoth o Other 

Del! id 6490) OCLlpMT 6500 

Coumadin; DYes 0 No DCCoum (6510) 

Direct Thrombin Inhibitors: DYes 0 No DCDirThromln 6511) 

Discharge Location: DHome o Extended Carerrransitional Care Unit/Rehab o Other Hospital 

DlsLoctn (6520) o Nursinq Home o Hospice OOther 

Cardiac Rehabilitation Referral: DYes 0 No o Not ~Qlicable CardRef (6530) 

Smoking Cessation Counseling: DYes 0 No o Not Applicable SmokCoun '6540 

S. Readmission 

Readmit <=30 Days from Date of Procedure' 0 Yes 0 No :' \;')~ Readm30 (6550) 

Readmit Primary Reason: ReadmRsn (6560) Readmit Primary Procedure: ReadmPro (6570) 

o Anticoagulation Complication - Valvular 

o Anticoagulation Complication - Pharmacological 

o Arrhythmia/Heart Block 

D Congestive Heart Failure 

D Myocardial Infarction andlof Recurrent Angina 

o Pericardial Effusion and/orTamponade 

o Pneumonia or other Respiratory Compiication 

o Coronary Artery Dysfunction 

o Valve Dysfunction 

o Infection - Deep Sternum f Mediastinitis 

o Infection - Conduit Harvest Site 

o Renal Failure 

DTIA 

D Permanent CVA 

o Acute Vascular Complication 

o Subacute Endocarditis 

o VAD Complication 

o Transplant Rejection 

OPE 

DWT 

o Other - Related Readmission 

o Other - Nonrelated Readmission 

© The Society ofThoracic Surgeons 2011 Page 16 of 16 

o OR for Bleeding 

o Pacemaker Insertion f AICD 

o PCI 

o Pericardiotomy I Pericardiocentesis 

o OR for Coronary Arteries 

o OR for Valve 

o OR for Sternal Debridement I Muscle Flap 

D Dialysis 

o OR for Vascular 

o No Procedure Performed 

o Other Procedure 

o Unknown 
232 


85440.183

Dr. Thomas. rods 

Chief ~ledical om"",. 

Independent U:eahh 

5 I 1 Farber Lake, Drive 

Williamsville, XY 1~22J 

Dear Dr. Foels: 

June 26. 2013 

rhank 'y1..~1l HJr appGnring before ihe SuhcommiH-c~ -on Heahh on \Vcdnesd.ay~ June 5~ 20 1 J~ to 

tcst!!)., at the hearing entitled ,;'Reforming SGR: Prioritizing Quality in a j"vlodcrnizcd Physician Payment 

Systcm.~~ 

PUf:;uant to the Rufes nfthc CmnmiUee on Energy and C0mmercC". the hearing record remains. 

-open for h .... n husinc$~ tIays. to permit h1embers {o submit additional questions Ibr the recQrd~ \.yhich arc 

auached. The format of you x responses to. these question.s should be as foHo\\.-s: (1) the l1<.HnC nf the 

l\1emhcr \yhose question you arc addrc-5sing, (2) the c(~1Hplctc text of the qm,~s-tioH you are addressing in 

hotd~ and (3) your ans\\'er to that {lUeS-lion in plain text. 

Abo attached .aTe iVielnber requests made during the hc~!ring, The Ibnnat of your responses to 

these requests should foHow the same fonnat as- your re:spon:'-':cs to the additional questions for the- record, 

To filclJitalc lhc printing orIlle hearing re('orrl~ please -r"Csf}ond to these questions and requests by 

the dose of business on Friday~ July 12. 2013. Your responses should be mailed to Sydnc llarwick, 

Legislative Clerk, Committct: on Em:rg:y and COJlHllCrCC, 2125 Ra)'burn House Office- BuHding. 

\Vas-hington. D.C. 205 I 5 and c-m-aUcd in \Vord f(}nnat to S"nlne-.Harwick1i:uutit'louse.go-,.'. 

Thank you again for your time and effort preparing and delivering tcsthl10ny before the 

Subcommittee, 

cc: The 1 Ion{}rabh~ Frank PnHone~ Jr.~ Ranking ;v1cmber, Subcommiuce on Health 

Atlac-hrnents 
233 


85440.184

Indep'€ndent 

• Health. 511 Farber Lakes Drive, Buffalo/ New York 14221 716.631.3001 W',VWjf1dependenthealth.com 

July 12, 2013 

5ydne Harwick 

Legislative Clerk, Committee on Energy and Commerce 

2125 Rayburn House Office Building 

Washington, D.C. 20515 

Ms. Harwick, 

Please find responses to the questions posed by members of the committee on Energy & Commerce as 

outlined in your June 26, 2013 letter. 

Sincerely, 

encl 

~==P:a~;~~~;~~~!s::~~N~ec.de';~~~~I=i=i~~I~~~~;to=~~I~:~j':~~~e~~:~~=:;I=~~~~jon; 

fndepe:tdl!!l1t !-{ca~ does.,~ <lC'Ce~t service of paper~ ~lectronlcally under CPlR 2103 
234 


85440.185
235 


85440.186

The Honorable Joseph R. Pitts 

1) From a payer perspective, Independent Health grapples with many of the same issues as CMS 

does with the Medicare program (albeit on a different scale). From the perspective of 

someone who has endeavored in such work with providers in New York, do you believe the 

types of measurement and model programs envisioned under the Committee's legislative 

framework to be of benefit to the Medicare program? 

Ves, I believe the committee's legislative framework as outlined in the "Discussion Draft: 

Reform of Sustainable Growth Rate (SGR) and Medicare Payment for Physician Services" 

contains important, key elements necessary to shift payment toward a pay-far-value program 

that recognizes and rewards performance and quality. 

SpeCifically, I believe: 

./' Quality measures (including functional, process and clinical outcome measures) 

currently exist and can be further developed that represent and differentiate the 

ability of primary care physicians and specialty physicians to provide clinical quality . 

./' Physicians and professional organizations representing physicians should be 

involved in metric development, attribution logic, risk adjustment methodologies 

and scoring systems . 

./' That development and implementation of quality measures must precede the 

broader movement toward alternative payment systems otherthan fee-for-service 

(FFS). Bundled payments, case payment, global population-based payments, and/or 

shared-savings reimbursement each have potential perverse incentives for underutilization. A robust collection of quality measurements and incentives must be 

established and operate concurrently with any such alternative payment systems . 

./' Public and peer-to-peer transparency of quality measurement is an important 

element of success for any such program. 

I believe additional considerations and discussions are necessary in the following areas: 

./ The development of "performance thresholds". Although operationally more 

challenging, physicians should be rewarded for incremental improvement toward 

goal. Maximum performance thresholds should be established (ie: at less than 

100%) since there are legitimate clinical exceptions to any practice guidelines; 

performance thresholds should not be established such that they would promote 

unintended patient harm as the result of inappropriately aggressive medical 

management nor promote "cherry picking" of patients by practitioners solely for the 

purpose of improving their performance scores . 

./' Clinical quality guidelines should be adopted which specifically address appropriate 

age/gender and disease co-morbities of the senior patient population. For example, 

blood glucose (AlC) goals and blood pressure goals for elderly adults may require 

differing clinical thresholds than these used for middle-aged adults. 
236 


85440.187

./' Physicians must be provided "actionable reporting" of performance in a manner 

that allows easy interpretation of results, trended reporting to allow providers to 

understand the impact of their previous interventions to improve care, regional 

peer comparisons, and educational initiatives (ie: "improvement literacy") to assist 

them in making necessary improvements in systems of care . 

./' Both primary and specialty care physicians should be held mutually responsible for. 

select quality measures. For example, cardiologists should receive reporting and be 

held responsible for basic quality metrics for diabetic patients under their care, 

since poorly controlled diabetes constitutes a major risk factor for coronary artery 

disease progression and stroke. 

21 You state in your testimony that one of the guiding principles of IHA are "substantive and 

sustainable improvement in quality and affordability ofthe American health care system will 

require movement away from traditional FFS reimbursement systems. Would you explain 

why FFS Medicare undercuts quality and affordability in our health care system? 

The fee for service system reimburses providers and hospitals solely upon a unit of service being 

performed. 

Here are some examples: 

./' An office visit to a primary care physician paid as one unit of service under fee-forservice reimbursement: In one scenario, the primary care physician successfully 

and effectively provides all clinically relevant, guideline-recommended services, 

including the coordination of all preventive screening, chronic disease testing for 

diabetes, smoking cessation recommendations, and other recommended 

anticipatory needs. Another primary care physician, spending in equal amount of 

time with the patient, might provide few or none ofthese services. Currently, in 

both cases, the physician is reimbursed equally with no recognition of the quality of 

services provided from that office visit . 

./' A specialist seeing a patient referred from a primary care physician does not have 

immediate access to previous x-rays or results of previous diagnostic tests. A 

physician taking additional administrative time to coordinate care by obtaining the 

results of these previous tests currently receives no recognition or financial 

remuneration for care coordination efforts; as a result, radiologic imaging and 

diagnostic testing have the potential to be repeated unnecessarily. 

In these two simple examples ofthe current fee-for-service (FFS) Medicare payment system, 

there's no differentiation of clinical physician services being rendered. In the first example" 

there is no recognition for the significant difference show in visit quality. In the latter example, 

there is no recognition or incentive to coordinate care in affordable manner, 

2 
237 


85440.188

3) You state in your testimony that primary care plays a pivotal and foundational role in the 

transformation to a high quality health care system. I also know that primary care is uniquely 

positioned in the health care market place to impact cost and quality. With the committee's 

legislative framework in mind, do you believe it possible to incentlvize primary care 

differently as a way of encouraging even greater quality and affordability in the system? For 

instance, maybe constructing different types of measures or performance benchmarks could 

lead to additional benefits In Medicare and patients? 

Yes, I believe that primary care is uniquely positioned to play such a pivotal and foundational 

role. A primary care physician acts as a "comprehensivist" ... uniquely and professionally trained 

to understand and manage a wide spectrum of clinical conditions. Having an established and 

ongoing relationship with a patient affords a primary care physician the ability to manage the 

patient longitudinally over time, both diagnostically and therapeutically. This alone provides 

value in that the primary care physician can manage the patient in a sequential way over time 

rather than being compelled to bundle services during a simple single episode of care. Also, the 

primary care physician is in a unique position to understand and manage co-morbid medical and 

behavioral health conditions. lastly, the primary care physician's comprehensive understanding 

of a patient's social needs can be addressed and factored into the patient's therapeutic plan. 

The inverted ratios of primary care physicians to specialists in the United States contributes to 

the significant imbalance of dema nd which exceeds capacity for the primary care phYSicians, yet 

allows enhanced capacity and access to specialists. Furthermore, since most Medicare eligible 

patients have multiple acute and chronic conditions, specialists (acting as "partlalists" rather 

than "comprehensivlsts") are unable to manage the full array of contributing conditions that 

might have warranted the referral visit. For example, diabetes is a strong contributor to 

cardiovascular disease (heart disease and stroke). A cardiologist, managing a diabetic patient 

with coronary artery disease, would typically not address or feel it their responsibility to comanage diabetes. Poor access to primary care and easy access to specialty care thus can 

contribute to missed preventative management opportunities and care disproportionalJy 

focused on the sequelae of uncontrolled disease. 

The restructuring of primary care in the United States will require a variety of solutions applied 

simultaneously. First, expanded training programs must be created to increase the number of 

physicians pursuing a professional career in primary care. Secondly, newly graduated and 

established primary care physicians should receive ongoing training and education in population 

management and team-based systems of care. Thirdly, primary care practices must receive 

enhanced reimbursement to address and balance the existing distortions in professional 

reimbursement across specialties and to provide sufficient capital for primary care physicians to 

reinvest in their professional staff, establish high-functioning care teams and acquire the 

necessary care management tools and technologies to provide population-based care in an 

effective and efficient manner. Fourth, measurements and incentives should be created to 

reward achievement of clinical outcomes, completion of critical clinical process measures,'and 

enhanced clinical efficiency. nmely measurement and feedback on performance, combined 

3 
238 


85440.189

with data transparency, meaningful incentives, and ongoing education (improvement literacy) 

will help drive cycles of continuous quality improvement. 

4) The legislative framework envisions a system in which providers might identify themselves 

for the purposes of measures. Do you think that such a system of quality benchmarks and 

measurements could also be applied to disease states such as diabetes or cancer? 

This is in essence a two-part question. First, providers should be allowed to identify which 

specialty peer category in which they wish to be measured. For example, many internist 

physicians are dual-boarded and provide both primary care and specialty care within their 

practices. Common examples are cardiology and gastroenterology. Depending on the 

proportion of their professional time spent in each area, they may wish to be categorized under 

either a primary care or specialty care category. In our experience at Independent Health with 

pay-for-performance programs, it is important to allow physicians to self-identify their specialty 

and be placed under the appropriate array of quality metrics. 

Secondly, I believe that quality measures and benchmarks can be established for many common 

disease states. The practical application of such disease- specific measures to physicians will be 

limited by: 

,/ The prevalence of the specific disease-state within a physician's Medicare patient 

population. Conditions with low prevalence will not be able to be measured with 

statistical validity on an individual physician basis. 

,/ Measurement should be conducted only when there is significant variation among 

providers or where median quality performance shows opportunities for 

improvement. For example, simply because a disease-specific metric can be 

generated does not mean it should be incentivized; being "easy to measure" differs 

greatly from "being important to measure". 

,/ Not all disease states or specialties will lend themselves to measurement in the near 

term. Efforts should be established to prioritize disease state focus within the 

Medicare population and develop measurement based upon these priority areas. 

Not all disease states nor all specialty disciplines require or would benefit from 

measurement, reporting and lncentivization. 

4 
239 


85440.190

5) You mention in your testimony that no singular payment system is sufficient to 

simultaneously promote quality, efficiency and effectiveness. Do you believe that entities like 

Independent Health can help Medicare develop and implement new and innovative payment 

mechanisms? 

I believe a hybrid approach toward physician payments should be carefully explored. Such 

hybrid payment systems would incorporate and apply the best attributes of a variety of 

payment systems accordingly. As presented in my previous written testimony, fee-for-service 

can be effectively maintained and employed toward potentially under-utilized clinical services. 

Global population-based prepayment is effective where there are viable, effective alternatives 

to delivering care other than face-to-face visits. Shared savings opportunities reward providers 

who work collaboratively with other physicians and institutions to provide effective care 

coordination. Lastly, quality-based payment serves as an important "check-and-balance" 

against potential underutilization and creates proper focus on clinical quality opportunities. 

Many commercial health plans, including Independent Health and especially those regional notfor-profit health plans affiliated with the Alliance of Community Health Plans (ACHP), have 

already undertaken innovative approaches toward payment reform. These plans, including 

Independent Health, have experience and important insight into the design and operational 

issues associated with alternative payment systems. Existing claims processing systems must be 

reconfigured to conform to the demands of any alternative payment system. As such, 

adaptation is challenging. Shared learning among innovative health plans with previous 

experience would prove of significant benefit to the federal agencies seeking to adopt 

alternative payment systems. 

6) While primary care and some specialty groups have a long standing history of measure 

development and performance, others unfortunately lag behind. Do you believe that all 

provider groups adopting a system of quality measurement will be good far the provision of 

care in this country, and do you believe that provider specialties that are advanced In these 

areas might be able to help those who lag behind? 

Please refer to my res pense to question 4. Medicare should prioritize areas of focus based upon 

population health needs and opportunities. I do not believe that it is either necessary or wise to 

work to develop quality performance metrics for each and every speCialty. Emphasis should be 

placed upon where there is demonstrable need for quality improvement. 

5 
240 


85440.191

7) How important is meaningful, timely feedback on performance for such a system to work? 

Meaningful, timely feedback is, perhaps, the most critical aspect of driving performance. There 

is now a long and significant history of physician pay-for-performance in the United States. 

Although there are many variables among these P4P programs, many have had disappointing 

long-term impact on im proving quality. 

Key attributes related to performance feedback of successful programs include: 

./ TImely reporting, such that changes in a physician's practice pattern can be 

demonstrated within the shortest interval possible • 

./ Trending data, such that physicians can see their progress toward goal over time . 

./ Establishing statistical confidence intervals, such that small sample sizes do not 

resu It in la rge fluctuations in performance over time simply due to statistical 

variation . 

./ Peer norms for comparison, especially among regional providers to whom providers 

most closely relate professionally . 

./ Drill-down reporting (to the patient-specific level) that would allow the providerto 

both confirm the validity of the performance report and take patient-specific action 

if cared needs are unmet. 

Independent Health has a long history of well-established phYSician-vetted, actionable reporting 

and would be available to discuss any such reporting in further detail to any interested party. 

6 
241 


85440.192

The Honorable John Shimkus 

1) Your testimony touches on one such model the "Primary Connections" practice. You 

state that shared savings models such as Primary Connections "have fostered greater 

collaborative efforts between primary care and specialty providers." Would you tell me 

what types of benefits providers, patients, and taxpayers might enjoy should this 

committee be successful and encourage broad adoption of shared savings and other 

altemative payment models in Medicare? 

Fundamentally, any individual patient's health care is delivered by a "team" of providers, a 

by-product of a system of care composed of multiple individuals. Some clinical teams are 

easily apparent, an example being a doctor, nurse practitioner and nurse within a solo 

practice. Other "teams" are less obvious and exist in a virtual sense yet they are 

collaborative team's none-the-Iess. For example, a primary care office, endocrinology 

office, cardiology office, and ophthalmology office is all part of a "virtual team" caring for a 

patient with diabetes. 

Optimal health care is the by-product of an optimal health care team. Unfortunately, "team 

performance" is neither regularly measured nor reported and, even less frequently 

reimbursed or incentivized or on team basis. 

The current fee-for-service (FFS) payment methodology unfortunately recognizes the efforts 

of individual team-members (not teams) and does so only based upon volume (activities), 

not upon the success or outcomes those activities. 

Shared savings programs have the ability to measure, report, and reward the efficient and 

effective performance of collaborative and coordinated care teams. Examples of shared 

savings opportunities include: 

./ Primary care provider offices selecting specialty referral sources based upon their 

efficiency, effectiveness and service attributes (referrals based upon performance 

transparency vs. based upon anecdotal relationships) . 

./ Rewards for improved communication and care coordination among providers in an 

effort to reduce non-value-added duplicate testing and procedures . 

./ Encourages development of new and innovative care systems that are focused on 

measureable outcomes of effiCiency and effectiveness (ex: home care programs as 

an alternative to an avoidable hospitalization) . 

./ Holistic care that addresses a patients' full spectrum of health care needs related to 

their condition in an effort to maximize clinical outcomes. [ex: clinical, behavioral, 

nutritional, sociall. 

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2) Page 21 of the legislative framework released last week calls for the development of a 

"process by which physicians, medical societies, health care provider organizations, and 

other entities may propose" Alternative Payment Models for adoption and use in the 

Medicare program. Do you believe that model development from private payers and 

providers like those at Independent Health can lead to reforms that could benefit 

patients, providers, and taxpayers? 

Many commercial health plans have implemented alternative payment models in recent 

years. This is especially true among regional not-for-profit health plans, who traditionally 

work closely and collaboratively with providers within their networks to develop payment 

systems that are built upon transparency, mutual trust, principles offairness (win-win) and 

designed to maximize operational ease for all parties. The Alliance of Community Health 

Plans (ACHP) is one such organization that represents health plans with alternative payment 

programs of proven success and sustainability. As there are many "lessons learned" already 

understood and cataloged by these early-innovator health plans, I would strongly 

encourage collaboration of CMS and the federal government with such organizations in an 

effort to speed development and deployment of alternative payment on a national level. 

8 
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The Honorable Gus Bilirakis 

1} How much of these quality measures should be developed for the physician in general or 

should we have measures for specific diseases? How do we develop quality measures for rare 

diseases? These are hard to diagnose diseases with small populations. If we do develop 

metries for specific conditions, how do we responsibly develop measurements for these 

conditions when research may be more limited? 

This is in essence a two-part question. First, providers should be allowed to identify which 

specialty peer category in which they wish to be measured. For example, many internist 

physicians are dual-boarded and provide both primary care and specialty care within their 

practices. Common examples are cardiology and gastroenterology. Depending on the 

proportion of their professional time spent in each area, they may wish to be categorized under 

either a primary care or specialty care category. In our experience at Independent Health with 

pay-for-performance programs, it is important to allow physicians to self-identify their specialty 

and be placed under the appropriate array of quality metrics. 

Secondly, I believe that quality measures and benchmarks can be established for many common 

disease states. The practical application of such disease- speCific measures to physicians will be 

limited by: 

.(' The prevalence ofthe specific disease-state within a physician's Medicare patient 

population. Conditions with low prevalence will not be able to be measured with 

statistical validity on an individual physician basis . 

.(' Measurement should be conducted only when there is significant variation among 

providers or where median quality performance shows opportunities for 

improvement. For example, Simply because a disease-specific metric can be 

generated does not mean it should be incentivized; being "easy to measure" differs 

greatly from "being important to measure" . 

.(' Not all disease states or specialties will lend themselves to measurement in the near 

term. Efforts should be established to prioritize disease states focus within the 

Medicare population and develop measurement based upon these priority areas. 

Not all disease states nor all specialty disciplines require or would benefit from 

measurement, reporting and incentivization. 

As a general rule, it is important to "measure what is important to measure" and to resist the 

urge to measure something simply because it is easy or based upon a perceived need to have a 

measure for all conditions(both common and rare) or all specialty disciplines. I would strongly 

encourage the adoption of quality measured based upon a prioritization process based upon: 

.(' Highest disease prevalence. 

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./' Greatest performance improvement opportunity (ie: wide existing variation in 

outcomes among providers or among regions) . 

./' Clinical areas not receiving sufficient focus or incentivization currently . 

./' Favorable return on investment (ROI) . 

./' Focus may vary by community; attempts should be made to recognize regional 

variation and the need to measure and incent proportionately (i.e.: create 

"community report cards" and incent community improvement). 

2) How much input should patient groups have and what type of input into the process should 

they have when determining these measures? 

! believe patient group might have their greatest impact in helping to delineate communityspecific and needs. A patient-centered approach toward metric development contributes to the 

sense of shared accountability among both patients and providers. A patient centered approach 

would also facilitate the development of publically transparent provider performance data 

reporting in a clear, concise and actionable format. 

3) Should the system evolve to allow a direct feedback loop to the doctor? For example, the 

physician would know that they were paid X because they did or did not do Y to patient Z. Do 

we want the granular a system, or should the information and payment be done on a more 

aggregate level? 

Actionable reporting is critical to performance improvement by providers over time. 

Physicians must be provided "actionable reporting" of performance in a manner that allows easy 

interpretation of results, trended reporting to allow providers to understand the impact of their 

previous interventions to improve care, regional peer comparisons, and educational initiatives (ie: 

"improvement literacy") to assist them in making necessary practice management improvements to 

establish improved systems ofcare. 

Meaningful, timely feedback is, perhaps, the most critical aspect of driving performance. There is 

now a long and significant history of physician pay·for-performance in the United States. Although 

there are many variables among these P4P programs, many have had disappointing long-term 

impact in improving quality. 

Key attributes of impactfuI, actionable reporting include: 

./' Timely reporting, such that changes in a physicia n's practice pattern can be 

demonstrated within the shortest time possible . 

./' Trending data, such that physicians can see progress toward goal over time. 

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./' Establishing statistical confidence intervals, such that small sample sizes do not 

result in huge fluctuations in performance overtime simply due to statistical 

variation . 

./' Peer norms for comparison, especially regional providers to whom providers most 

closely relate professionally . 

./' Patient-specific "Exception reports" so that providers can determine the validity of 

their performance reports and so that they can act upon unmet clinical needs on a 

patient specific basis. 

Independent Health has a long history of well-established physician-vetted, actionable reporting 

and would be happy to discuss this in further detail to any interested party. 

For example, recent quality improvement efforts at Independent Health involved the application 

of common diabetic quality metrics to both primary care physicians and to cardiologists who 

were co-managing these same diabetic patient populations. An important clinical perspective 

worthy of emphasis is that a patient's underlying diabetic state places them at significantly 

higher risk for corona ry vascular disease. The mere fact that this patient is under the care of a 

cardiologist may well be an indication that diabetes is a strong contributing causative factor to 

their current heart disease. Collaborating cardiologists in our program were, at first, reluctant 

to be held mutually accountable for diabetic quality metrics involving patients under their care, 

declaring "it is the primary care physician's responsibility to manage diabetes, not mine". Yet, 

when confronted with performance data demonstrating poor diabetes control and management 

of patients under their care, cardiologists began to recognize the important role they play in comonitoring a patient's compliance with needed care. 

4) Is it possible to use physician quality measures to encourage patients to better follow doctor's 

plan to manage diseases? For example, a newly diagnose diabetic getting a follow up call by 

the doctor reminding them to check their blood sugar or reminding them to schedule an 

appointment with a nutritionist. Should these metries be limited to what is done inside the 

physician's office? 

Two issues are raised in this question: patient engagement and making primary care physicians 

and specialists mutually accountable for quality outcomes and performance. 

The regard to the former, it would be intriguing to consider establishing an individual "patient 

report card" that would list out forthe patient the services they should be receiving, with an 

accompanying report of whether these needed services have been met or unmet. For example, 

although physicians are asked to adopt a best practice clinical guideline for diabetic care 

management and have various quality measures based upon the tenants of such a clinical 

practice guidelines, it would be ideal for patients to receive a similar best practice guideline 

outlining the care they should also follow. If such a document were to be created, patients 

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would have a much dearer expectation oftheir disease-specific and health maintenance needs 

and could themselves, become more fully engaged in conversations with their physicians 

regarding mutually acceptable disease management goals. 

As to the latter issue of holding multiple physicians mutl/ally accountable for quality 

performance along with primary care physicians, it is important to recognize that 

fundamentally, any individual patient's health care is delivered by a "team" of providers, a byproduct of a system of care composed of multiple individuals. Some clinical teams are easily 

apparent, an example being a doctor, nurse practitioner and nurse within a solo practice. Other 

"teams" are less obvious and exist in a virtual sense yet they are collaborative team none-theless. For example, a primary care office, endocrinology office, cardiology office, and 

ophthalmology office are all part of a "virtual team" carrying for a patient with diabetes. 

Optimal health care is the by-product of an optimal health care team. Unfortunately "team 

performance" is neither regularly measured nor reported and, even less frequently reimbursed 

or incentivized as a team. 

The current fee-for-service (FFS) payment methodology unfortunately recognizes the efforts of 

individual team-members (not teams) and does so only based upon volume (activities), not 

upon the success or shortcomings those activities (outcomes). 

5) Should the quality measure be weighted? If there are 10 things that a doctor can do to 

increase their performance measure, should they be rated equally for payment bonuses or 

weighted to account for time or difficulty? 

In regard to the relative weighting of quality measures, there are various important 

considerations. The most commonly used weighting methodology is to allocate more weightto 

outcome measures than to process measures. To site a common example, performance would 

be more heavily weighted to achieving blood sugar control in a diabetic patient (A1C within 

control; an outcome measure) than to simply obtaining the screening test within the 

appropriate time period (A1C test complete; a process measure). 

Alternatively, one might weight measures based upon some other criteria, for example, placing 

more heavy weight upon metrics where there exists the lowest current performance level (i.e. 

largest improvement opportunity) or on individual metrics that might provide the greatest 

return on investment. It might also be appropriate to vary weighting based upon specific 

community or regional needs and priority areas. A uniform or standardized national weighting 

methodology might place too much emphasis on a quality metric needing little additional 

Improvement within an individual community, yet place too little emphasis on a community 

quality metric truly deserving of additional focus. 

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85440.198

One additional methodology for weighting is the creation of a "quality composite index". A 

quality composite index is the sum of all numerators divided by the sum of all denominators 

across a spectrum of different and often unrelated quality metrics. An example would be: 

Quality Composite Index = 01 numerator + Ol numerator + 03 numerator = (Oln + 02n + 03n) 

01 denominator Q2 denominator Q3 denominator (Old + Old + Q3d) 

Q1, Q2, Q3 = represent three district and unrelated quality metrics 

N = numerator or number of patients meeting quality metric goal 

D = denominator or number of patients eligible for measurement under that individual metric 

Q1 = diabetic patients receivingA1Ctest annually 

= 230 received test = 76% 

300 eligible 

Q2 = post myocardial infraction patients receiving aspirin therapy 

= 22 received aspirin = 88% 

25 eligible 

Q3 " colorectal cancer screening 

= 49 received screening" 65% 

75 eligible for screening 

Quality Composite Index '" (230 + 22 + 49) = 301 '" 75% 

(300 + 25 + 75) 400 

In this example of a composite index, each individual metric is automatically weighted upon the 

proportion of a physician's patient panel which meets eligibility criteria for that measure. Thus, diabetes 

(300 eligible) is inherently weighted more heavily than post myocardial infraction patients (only 25 

eligible). In dOing so, the differences which inherently exist in patient mix and disease-state composition 

between one physician vs. another phYSician are taken into consideration. A physician practice with 

very few post myocardial infarction patients but many diabetic patients would be weighted differently 

than a practice with the diverse mix of patients and disease states. In each case, measurement 

automatically adjusts to reflect the composite "best practice score" based upon multiple clinical 

parameters across each physician practice. 

The composite index also eliminates the need to establish a minimum patient threshold for each quality 

metric. A physician practice with a small Medicare membership may have no single quality metric 

denominator reaching statistical significance; yet summing all clinical quality opportunities into a single 

composite index would be respectful ofthat practice's aggregate clinical quality opportunity. 

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85440.199

Weighting for "time and difficulty" is yet another methodology for consideration. Although it might be 

challenging to quantitate professional resource investment attribute for any individual quality metric, it 

would seem possible to achieve consensus from a qualitative perspective (Le. obtaining an A1C test is 

relatively more easy and less resource intense than managing a patient A1C blood sugar to goal, which 

might require multiple office visits and medication changes over time). 

14 
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85440.200

The Honorable John D. Dlngell 

1) During the hearing, you agreed that Congress should look at the innovations and changes 

being made In the private sector when considering reforms to SGR. Would you please list 

some suggestions of what you feel might be useful? 

Attached is a paper that describes payment models implemented by Independent Health and several 

other members ofthe Alliance of Community Health Plans (ACHP). There are a number ofthemes that 

emerge from our and others' experience with payment models that reduce reliance on fee-for-service. 

These include: 

Payment models should be structured to put primary care at the center of the system. Payment 

should recognize the care coordination and integrative functions ofthe primary care clinician. 

Primary care physicians need information about which specialists and hospitals are more effective 

(quality) and more efficient (cost). Especially when combined with innovative benefit deSigns that 

encourage patients to choose high value care, these payment models provide strong incentives for 

primary care phYSicians to take responsibility forthe quality of care and the cost associated with a 

defined patient population. 

Payment models should be phased in over time, starting with !'upside risk" (shared savings, but not 

shared loss). This fosters trust and confidence among physician practices and allows time for 

physicians to improve their ability to manage a population before moving to a shared risk 

arrangement. 

• Meaningful and transparent quality and cost measures are a key element. Payment models must be 

connected to measures that are meaningful to patients and physiCians, reflecting both outcomes 

and the overall cost of care. The attached paper lists a number of measures that often are used to 

reward physician performance, including preventive health and disease management measures as 

well as measures of total cost that use risk-adjusted ratios to compare physicians to peer groups. 

• Building relationships with physicians is critical. Getting provider buy-in to new payment 

arrangements that are aligned with outcomes and efficiency measures is an essential component of 

payment reform. Such buy-in includes work with phYSicians to explain and benchmark performance, 

soliciting their professional judgment on the best measures, and including other community 

stakeholders to ensure broad support for the use of transparent metrics and incentives tied to those 

metrics. 

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85440.201

Please see the attached document ("ACHP Approach to Payment Reform)- which includes additional 

details of various innovative alternative reimbursement programs among several regional not-forprofit health insurers. 

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ACHP Approach to Payment Reform - Response to October 3, 2012 Meeting 

ACHP member organizations have been leaders in restructuring physician payment and moving away from feefor-service for many years. Our health plans have adopted these payment reforms in order to align the goals of 

payers and physicians in keeping people healthy and providing care that is of the highest quality and value. As 

innovators in different areas of the country, our member organizations have developed physician incentive 

programs that meet the needs of practices in their communities-whether physicians are delivering care as sole 

proprietors, multi·specialty clinics or integrated health systems. One unifying characteristic is the 

simultaneous focus on quality, efficiency, and patient satisfaction. 

ACHP health plans support practices financially through one or more of the following mechanisms: 

stipends or transformation "seed money"; 

bundled payments; 

pay-for·performance; 

enhanced fee-for·service payments; 

shared savings/gain sharing, and or shared risk; 

care coordination/care management fees 

One area of particular innovation, for both integrated systems and health plans that contract with providers (as 

well as mixed· model health plans), is the Patient-Centered Medical Home. ACHP members see the medical 

home as a way of transforming primary care and placing it at the center of their care system. They have 

moved beyond structure (i.e., payment for simply reaching a certain level of Medical Home status) to payment 

arrangements that combine FFS payments with incentives for quality, efficiency/utilization, outcomes, and 

patient satisfaction and access. Several ACHP members have started out with smaller quality incentives (e.g., 

5%) and moved to arrangements over time in which a primary care physician's reimbursement can be increased 

significantly by delivering high-quality, efficient care. These payments are still in the context of more limited 

thoughtful and appropriate risk exposure than traditional capitation payment models. Under these 

arrangements, payment can be a combination of fee-for·service, capitation, quality incentives, and rewards for 

efficiency. Specific examples of these arrangements can be found at the end of this document. The variations 

in the models reflect the significant variation in the degree of medical system integration and capability but all 

drive toward accountability for triple aim performance and set up dynamics that reward top performers. 

What We're Learning - Key Themes 

New models for payment are necessary, but by no means sufficient to truly reform care delivery and incent 

physicians. Payment reform must be integrally linked to efforts to create a higher degree of integration and 

collaboration between payers and providers, and requires some degree of flexibility for regional customization. 

It is also critical to acknowledge that payment models aligned with Triple Aim objectives are also necessary but 

not sufficient. New models for physician payment must also have a clear connection to the ideal of 

professionalism that drives much physician behavior. An example of this is the impact of public reporting of 

clinical quality results that, in some markets, has led to steady, year over year performance improvement. 

The following pages represent a summary of these key themes, with examples underneath each, in response to 

the request for further detail on ACHP plans' experience with alternative payment models. 

MAKING HEALTH CARE 

1825 Eye Street, NW, Suite 401 I Washington, DC 20006 I p: 202.785.2247 I f: 202.785.4060 I www.achp.org 
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85440.203

Require Reporting of Meaningful and Transparent Quality Measures 

Models must be connected to measures that are meaningful to patients, physicians and have an impact on 

lowering the overall cost of delivering care. 

We reviewed the measures that the six health plans that participated in the October 3 meeting (Capital District 

Physicians' Health Plan, HealthPartners, Independent Health, Priority Health, Tufts Health Plan and UPMC) 

used for commonalities, and found that the performance on the following HEDIS· treatment and screening 

measures are often used as a "threshold" for physicians to earn additional bonus payments for cost and patient 

experience performance. 

Health Care Outcomes: Preventive Health 

Cervical cancer screening 

Mammogram screening 

Chlamydia screening 

Glaucoma screening 

lead testing in children 

child/adolescent well care visits 

childhood immunizations 

Health Care Outcomes: Disease Management 

Diabetes Care (HbA1c testing and control, LDL testing, nephropathy monitoring, complete lipid profile, eye 

exam) 

Asthma care management 

Appropriate testing for children with pharyngitis 

Appropriate treatment for children with URI 

For Cost/Utilization Measures, the following represents commonalities we found in a high·level analysis: 

CDPHP, Health Partners and Independent Health: These plans use risk·adjusted ratios to determine their 

efficiency index. They compare the total cost relative to peers in the same network/peer group. Health 

Partners measures total cost and utilization separately using two calculations, whereas CDPHP and Independent 

use one formula. 

Health Partners formulas: 

o Total Cost Index = Risk Adjusted Per Member/Per Month PMPM / Peer Group Risk Adjusted 

PMPM 

o Resource Use Index = Risk Adjusted Resource Use PMPM / Peer Group Average Risk Adjusted 

Resource Use PMPM 

CDPHP formula: 

o Total cost of care Index relative to peers in network including ED, Hospital, Lab, Radiology, Rx, 

Specialists (Risk adjusted and expressed as a ratio: observed/expected) 

Independent Health formula: 

o Total Cost Index = Risk Adjusted PMPM / Peer Group Risk Adjusted PMPM 

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Phase in Provider Risk-Sharing: Start with Shared Savings 

The ACHP plans have found it productive to start with purely "upside risk" (sharing savings, but not sharing 

loss), as part of building trust and confidence in physician practices. Physician practices are not used to 

managing risk, so health plans have achieved buy-in to payment restructuring by sharing savings with providers 

but, initially absorbing losses themselves. As provider organizations gain skill and confidence in their ability to 

manage a population, they are in a better position to take accountability for downside risk. It also assures that 

both plans and providers are selecting categories of risk that providers can control. Many of the ACHP plans 

with innovative payment models are in transition stages, moving from pay-for-performance to gain sharing that 

is purely upside, to gain sharing that carries some downside risk. 

Even within a single ACHP member plan, there are often multiple versions of an incentive program -- meeting 

the provider practice where it is in structural and technological capabilities. The goal of these arrangements is 

to drive physicians to greater innovation, more responsibility for total costs of care, and properly aligned 

incentives around patient'centered care over time. 

Example: 

Tufts Health Plan's (THP) value·based global payment strategy is based on a systematic approach that engages 

both providers and consumers in health care decisions. The Coordinated Care Model is a three-pronged 

approach that focuses on the alignment of behavior through provider engagement, product design and care 

management. Provider engagement creates a collaborative alignment around an appropriate level of financial 

risk - shared vs. full· based on a group's readiness to assume risk. THP assesses each group's readiness to 

assume risk along several attributes. Groups must possess apprapriate levels af physician leadership, system 

integratian and cultural alignment and internal pravider incentive structures. The plan also looks at 

organizational infrastructure related to primary care access, referral management approaches, care 

management capabilities and data and analytic capacities. Appropriate risk motivation and alignment along 

these attributes are used as determinants of likely success under a risk based contract. This construct informs 

the plan's decision on the appropriate level of initial risk and the progressive increases in risk shared by the 

provider. 

Structure Payment and Relationships to Put Primary Care at the Center of the Care System 

ACHP's health plans' focus on primary care reflects our belief that the primary care physician should be at the 

center of a system that is responsible for the health of a defined total population. ACHP member plans provide 

primary care physicians with information about which specialists and hospitals are more efficient (cost) and 

more effective (quality). Especially when combined with innovative benefit designs that encourage patients to 

choose high value care, the plan puts the primary care physician in a position to coordinate care with 

specialists and other providers and supports them with both the necessary analytical information and the 

financial incentives to do so. It is clear, however, that to realize the full potential of payment reform, one 

must extend accountability and transparency to specialty categories of care as well as hospital care. 

Example: 

Independent Health has spent a great deal of time building a coalition of respected, well recognized highperforming primary care physicians who work collaboratively with each other, specialty physicians, and other 

providers to improve the health of the population. This coalition and its approach to health care delivery is 

known as Primary Connections. It is a physician-led, physician-driven initiative, with the health plan as 

facilitator and collaborator, that includes: 

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Innovative hybrid reimbursement model: pay for value with opportunity to share savings 

Enhanced access to analytical data and information 

Deep collaboration between primary care providers and specialists 

Access to dedicated resources: case managers, behavioral therapists, pharmacists, nutritionists 

Building trust 

The importance of building relationships with physicians over time cannot be overstated. Getting provider buy· 

in to new payment arrangements that are aligned with outcomes measures is an essential component of 

payment reform. Such buy·in includes on-the-ground work with physicians to explain and benchmark 

performance, along with participation with other community stakeholders to ensure broad support and buy-in 

to the metrics used for incentives. Absent the hard work of developing those relationships, providing the 

information needed to promote success and aligning incentives between payer and provider, payment reform is 

not likely to be successful. These connections have been a successful means of drawing a credible connection 

between aligned payment models, measures of clinical quality, and patient experience and the ideal of 

professionalism held by the great majority of providers. 

One way to engender trust is to acknowledge and solicit the leadership of phYSicians in identifying clinical 

needs for the community and developing the programs to address the need. Economic alignment should follow 

(quickly) upon clinical alignment. 

Example: 

Through ongoing financial support and engagement with regional quality collaboratives such as the Institute for 

Clinical System Improvement and Minnesota Community Measurement, HealthPartners has helped establish 

forums for grappling with some of the most difficult issues arising from attention to the Triple Aim. These 

forums involve providers from all types of practices as well as the majority of payers in great Minneapolis 

region and have helped the community move along the path to delivering on the Triple Aim where other 

communities may have stalled. HealthPartners has used work results from these collaboratives, combined with 

its own supporting analytics, pay for performance and recognition programs, tiering, patient information, and 

product design to create consistent market signals tailored to the capabilities of its care delivery partners. 

This provides a visible path to SUCCess on all Triple Aim objectives while pushing continued transformation. 

Summary 

These models are reflective of six ACHP member organizations. Many other ACHP members are also 

implementing alternative models to fee·for-service for both primary care and specialty physicians. All of our 

members recognize the importance of linking payment to meaningful measures, involving physicians in the 

design of new models, and ensuring quality patient care is a key driver behind all payment innovation. We are 

happy to provide more information about the models from the plans featured in this brief document, as well as 

other ACHP organizations' approaches to payment. 

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Examples of Models: 

Independent Health 

Hybrid reimbursement model: 

(1) FFS for preventive services, immunizations, in~offke procedures and labs 

(2) Prepaid ,risk-adjusted monthly care coordination fee (includes previous FFS services other than 

preventive services with enhancement to help capitalize practices investment in the development of 

new care systems and skilled ancillary staffing). 

(3) Shared Savings: potential to share in total cost of care savings for their attributed patient population: 

must meet quallty thresholds to access shared savings. 

,·jll." "'"/',\ 'I'. 

1.5x and 2.Ox refers to the opportunity for physicians to make up to one and a half times their current 

reimbursement. 

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Capital District Physician's Health Plan - Enhanced Primary Care 

160 

140 

" 0 

120 '" [:l 

" ., 

0-

E 100 0 

u 

~ 

0 

., 80 on 

.s 

" '" GO ~ 

'" "-

40 

20 

0 

Tufts Health Plan 

~ Providers are 

paid when they 

provide a unit of 

service 

Traditional Model 

~ Providers are 

paid fee-forservice, with a 

portion of 

reimbursement 

tied to efficiency 

andlor quality 

performance 

PIP 

Care 

Coordination 

~ Providers and 

payers share in 

the gains of 

achieving a lower 

cost than target 

'---------~--~...------~~--' 

2011 51,7% 4,3% 

2012 27J% 4,3% 

Change -24.0% 0.0% 

Bonus 

EPe Model 

• Upside and 

downside risk is 

shared between 

THP and provider 

24.2% 

48,1% 

+24.0% 

" Providers adopt 

100% risk above 

and below a 

negotiated PMPM 

budget amount 

19,8% 

W8% 

0.0% 

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UPMC Model (PCMH) 

2006-2011 Current Future State 

Gain Share 

Gain is derived from improved coordination and management 

of services; decreased admits/ER visits/diagnostic services 

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